Doral Dental Services of Illinois...Doral Dental Services of Illinois, LLC 10 4) Doral’s Customer Service Department at 888.281.2076 The eligibility information received from either

Doral Dental Services of Illinois, LLC

Effective January 1, 2006

Dental Office Reference Manual

12121 N. Corporate Parkway Mequon, WI 53092

888.281.2076 Fax 262.241.7401

http://www.doralusa.com/

This document contains proprietary and confidential information and may not be disclosed to others without written permission.

©Copyright 2005 All rights reserved.

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Doral Dental Services of Illinois, LLC 3

Doral Dental Services of Illinois, LLC Address and Telephone Numbers

Doral Dental Services of Illinois, LLC Customer Service (For Medical Assistance Participants) 12121 North Corporate Parkway Mequon, WI 53092 1.888.286.2447 Fax: 262.834.3450 TTY (Hearing Impaired) 1.800.466.7566 Information Systems 12121 North Corporate Parkway Mequon, WI 53092 1.888.875.7482 Prior Authorization/Retrospective Review 12121 North Corporate Parkway Mequon, WI 53092 1.888.875.7482 Fax: 262.241.7150 Email: [email protected] Prior Authorizations and Retrospective Reviews should be sent to: Doral Dental Services of Illinois, LLC Prior Authorizations 12121 North Corporate Parkway Mequon, WI 53092 Dental claims should be sent to: Doral Dental Services of Illinois, LLC Claims 12121 North Corporate Parkway Mequon, WI 53092 Electronic files or diskettes should be sent to: Doral Dental Services of Illinois, LLC Information Systems 12121 North Corporate Parkway Mequon, WI 53092 Provider Relations (Claims Questions) 12121 North Corporate Parkway Mequon, WI 53092 1.888.875.7482 Fax: 262.241.7379 Email: [email protected]

Healthcare and Family Services 201 South Grand Avenue East Springfield, IL 62763 1.217.524.7478 HFS Provider Hotline 1.800.842.1461 HFS Participant Hotline 1.800.226.0768 TTY (Hearing Impaired) Hotline 1.877.204.1012 Department of Specialized Care for Children 2815 West Washington Suite 300, Box 19481 Springfield, IL 62794-9481 1.800.322.3722 Fair Hearings (Appeals) Healthcare and Family Services Bureau of Administrative Hearings 401 South Clinton Street, 6th floor Chicago, IL 60607 1.800.435.0774 Fraud Hotline 1.800.252.8903 TTY (Hearing Impaired) Fraud Hotline 1.800.447.6404

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mailto:[email protected]



Statement of Participant Rights and Responsibilities

The mission of Doral is to expand access to high-quality, compassionate healthcare services within the allocated resources. Doral is committed to ensuring that all Participants are treated in a manner that respects their rights and acknowledges its expectations of Participant’s responsibilities. The following is a statement of Participant’s rights and responsibilities.

1. All Participants have a right to receive pertinent written, and up-to-date information about Doral, the managed care services Doral provides, the participating dentists and dental offices, as well as Participant rights and responsibilities.

2. All Participants have a right to privacy and to be treated with respect and recognition of their dignity when receiving dental care, which is a private and personal service.

3. All Participants have the right to fully participate with caregivers in the decision making process surrounding their health care.

4. All Participants have the right to be fully informed about the appropriate or medically necessary treatment options for any condition, regardless of the coverage or cost for the care discussed.

5. All Participants have the right to voice a complaint against Doral, or any of its participating dental offices, or any of the care provided by these groups or people, when their performance has not met the Participant’s expectations.

6. All Participants have the right to appeal any decisions related to patient care and treatment.

7. All Participants have the right to make recommendations regarding Doral’s/Healthcare and Family Service’s Participant rights and responsibilities policies.

Likewise:

1. All Participants have the responsibility to provide, to the best of their abilities, accurate information that Doral Dental and its participating dentists need in order to provide the highest quality of health care services.

2. All Participants have a responsibility to closely follow the treatment plans and home care instructions for the care that they have agreed upon with their health care practitioners

3. All Participants, have the responsibility to participate in understanding their health problems and developing mutually agreed upon treatment goals to the degree possible.

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Statement of Provider Rights and Responsibilities Enrolled Participating Providers shall have the right to:

1. Communicate with patients, including Participants regarding dental treatment options.

2. Recommend a course of treatment to a Participant, even if the course of treatment is not a covered benefit, or approved by Healthcare and Family Services/Doral.

3. File an appeal or complaint pursuant to the procedures of Healthcare and Family Services /Doral.

4. Supply accurate, relevant, factual information to a Participant in connection with a complaint filed by the Participant.

5. Object to policies, procedures, or decisions made by Healthcare and Family Services /Doral. Likewise: 1. If a recommended course of treatment is not covered, e.g., not approved by Healthcare and Family

Services/Doral, the participating dentist, if intending to charge the Participant for the non-covered services, must notify the Participant. See Section 2.01 of the DORM.

2. A provider intending to terminate participation in the HFS dental program due to retirement, relocation

or voluntary termination is requested to provide Doral with written notification of termination at least 90 days prior to expected final date of participation. A list of existing Illinois Medical Assistance Dental Program patients currently in treatment and the treatment status should accompany notification. All other patients should be referred to the Doral‘s toll free referral number (1.888.286.2447) to find another dentist in the area taking referrals when services are needed.

3. A provider may not bill both medical and dental codes for the same procedure.

* * * Doral makes every effort to maintain accurate information in this manual; however, will not be held liable for any damages directly or indirectly due to typographical errors. Please contact us should you discover an error.

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Dental Office Reference Manual Table of Contents

Section Page 1.00 Patient Eligibility Verification Procedures................................................................................... 9

1.01 Participant Identification Card............................................................................................. 9

1.02 Handbook for Providers of Medical Services...................................................................... 9

1.03 Doral Eligibility Systems...................................................................................................... 9 1.04 KidCare Program Copayments......................................................................................... 11 1.05 Expanded Dental Services for Certain Participants.......................................................... 11 1.06 Consent Process for DCFS Wards ................................................................................... 12 1.07 Doral Customer Service Numbers .................................................................................... 12

2.00 Covered Benefits.......................................................................................................................... 13

2.01 Payment for Non-Covered Services ................................................................................. 15 2.02 Electronic Attachments ..................................................................................................... 15 A. FastAttach..................................................................................................................... 15 B. OrthoCAD ..................................................................................................................... 15

3.00 Prior Authorization, Retrospective Review, and Documentation Requirements .................. 16 4.00 Dental Services in a Hospital Setting......................................................................................... 18 5.00 Claim Submission Procedures (claim filing options)............................................................... 19

5.01 Electronic Claim Submission Utilizing Doral’s Internet Website....................................... 19 5.02 Electronic Claim Submission via Affiliated Network Services (ANS)………………………19 5.03 Electronic Claim Submission via ClearingHouse.............................................................. 19 5.04 HIPAA Compliant 837D File.............................................................................................. 19

5.05 Paper Claim Submission................................................................................................... 20

6.00 Inquiries, Complaints and Appeals ............................................................................................ 21

6.01 Receipt and Audit of Claims.............................................................................................. 24 7.00 Health Insurance Portability and Accountability (HIPAA) ....................................................... 25 8.00 Utilization Management Program ............................................................................................... 26 8.01 Introduction ....................................................................................................................... 26 8.02 Community Practice Patterns ........................................................................................... 26

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8.03 Evaluation ......................................................................................................................... 26 8.04 Results .............................................................................................................................. 26 8.05 Fraud and Abuse .............................................................................................................. 27 9.00 Quality Improvement Program ................................................................................................... 28 10.00 Dental Services Provided Out-of-Office ................................................................................... 29 ATTACHMENTS General Definitions ..........................................................................................................................A Healthcare and Family Services Identification Card Information.....................................................B Dental Claim Form and Instructions ................................................................................................C Malocclusion Severity Assessment (Salzmann) and Instructions ...................................................D HIPAA Companion Guide ................................................................................................................E Provider Change Form.....................................................................................................................F Requirements and Guidelines Patient Recall System Requirements ................................................................................ G Patient Record ....................................................................................................................H Office Claim Audit ................................................................................................................ I Radiology Guidelines .......................................................................................................... J Initial Clinical Exam Form ...................................................................................................K Recall Examination Form.................................................................................................... L Authorization for Dental Treatment.................................................................................... M Medical and Dental History .................................................................................................N Fee Schedule-Children ................................................................................................................... O Fee Schedule-Adults........................................................................................................................P Covered Benefits - Children............................................................................................................ Q Covered Benefits - Adults ................................................................................................................R

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1.00 Participant Eligibility Verification Procedures 1.01 Participant Identification Card

Medical Assistance Participants are issued identification cards monthly.

Providers are responsible for verifying that Participants are eligible at the time services are rendered and to determine if Participants have other health insurance.

Doral recommends that each dental office make a photocopy of the Participant’s identification card each time treatment is provided. It is important to note that the identification card does not need to be returned should a Participant lose eligibility. An identification card guarantees that a Participant is currently enrolled in the Medical Assistance Program for the dates identified on the card.

If medical coverage is restricted in any way, a printed message will appear on the front of the card. Examples of these printed restriction messages include:

QMB Only: Participant is eligible for medical benefits only. The

Participant is not covered for dental benefits. Illinois Healthy Women: (The Illinois Healthy Women card is pink.)

Coverage limited to family planning exams, birth control, pap smears, mammograms, labs, and diagnostic tests related to family planning and treatment of STD’s found at a family planning visit. There are no copays for family planning services. Certain other prescription drugs may be subject to copays.

Non-citizen Renal: Only End Stage Renal Disease services are covered. Organ

transplants and other related services are not covered. Spenddown Participants receive identification cards only for periods when their spenddown has been met and they are actually eligible for payment for their medical (and dental) expenses. See Attachment B for a copy of the card and an explanation of the information contained on the card. For additional information concerning Participant Identification Cards, please contact Doral’s Provider Relations Department at 1.888.875.7482.

1.02 Handbook for Providers of Medical Services

The Department’s Handbook for Providers of Medical Services is available for your review at http://www.hfs.illinois.gov/handbooks/ .Please refer to Chapter 100 (General Policy and Procedures), provider information necessary for providers to receive payment from the Department. If you do not have access to the Internet, please call 217.782.0538 or 217.524.7306 to request a copy of the handbook.

1.03 Doral Eligibility Systems

Enrolled Participating Providers may access Participant eligibility information through:

1) Doral’s Interactive Voice Response (IVR) system (eligibility hotline at 888.875.7482)

2) the “Providers Only” section of Doral’s website at www.doralusa.com 3) Affiliated Network Services’ (ANS) website at www.ANSlink.com

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http://www.hfs.illinois.gov/handbooks/


4) Doral’s Customer Service Department at 888.281.2076

The eligibility information received from either system will be the same information you would receive by calling Doral’s Customer Service Department; however, by utilizing either system you can get information 24 hours a day, 7 days a week without having to wait for an available Customer Service Representative. Access to eligibility information via the IVR line To access the IVR, simply call Doral’s Customer Service Department at 888.281.2076 and press 1 for eligibility. The IVR system will be able to answer all of your eligibility questions for as many Participants as you wish to check. Once you have completed your eligibility checks, you will have the option to transfer to a Customer Service Representative to answer any additional questions, i.e. Participant history, which you may have. Using your telephone keypad, you can request eligibility information on a Medical Assistance Participant by entering your 6 digit Doral location number, the Participant’s recipient identification number and an expected date of service. Specific directions for utilizing the IVR to check eligibility are listed below. After our system analyzes the information, the patient’s eligibility for coverage of dental services will be verified. If the system is unable to verify the Participant information you entered, you will be transferred to a Customer Service Representative.

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Directions for using Doral’s IVR to verify eligibility: 1. Call Doral Customer Service at 888.875.7482. 2. When prompted, press 1 to select eligibility verification. 3. When prompted, enter your 6 digit Doral Location ID. 4. When prompted, enter the Participants ID, less any alpha characters that may be part of

the ID. 5. When prompted, enter an expected date of service in DDMMYYYY format. 6. Upon system verification of the Participant’s eligibility for the date of service you entered,

you will be prompted to verify the eligibility of another Participant, make a claim inquiry or make a benefit inquiry.

7. If you choose to verify the eligibility of an additional Participant(s), you will be asked torepeat steps 4 and 5 above for each Participant.

8. If you choose to make a claim or benefit inquiry, you will be transferred to a Customer Service Representative.

Access to eligibility information via www.doralusa.com Doral’s Internet currently allows Enrolled Participating Providers to verify a Participant’s eligibility as well as submit claims directly to Doral. You can verify the Participant’s eligibility on-line by entering the Participant’s date of birth, the expected date of service and the Participant’s identification number or last name and first initial. To access the eligibility information via Doral’s website, simply log on to the website at <www.doralusa.com>. Once you have entered the website, click on “Doral Dental USA” and then click on “For Providers Only.” You will then be able to log in using your password and ID. First time users will have to register by utilizing their 6 digit Doral Location ID, office name and office address. Please refer to your payment remittance or contact Doral’s Customer Service Department at 888.875.7482 to obtain your location ID. Once logged in, select “eligibility look up” and enter the applicable information for each




Participant you are inquiring about. You are able to check on an unlimited number of patients and can print off the summary of eligibility given by the system for your records. Access to eligibility information via www.ANSlink.net

Enrolled Participating Providers may also verify Participant eligibility via Affiliated Network Services’ website at www.ANSlink.net. You can verify the Participant’s eligibility on-line by entering the Participant’s date of birth, the expected date of service and the Participant’s identification number or last name and first initial. When online, type www.ANSlink.net into the web browser. This will take you to the screen that allows you to enter the ANSLink® system. After pressing the enter button, the log-in screen will appear. If the office signing-in has a user ID and password, that information is entered in the appropriate spaces. If it is the first time for an office using the system, the ”NEW OFFICE” button is selected, which will take the user through a step-by-step registration process to gain access into ANSLink®. If you have questions on verifying eligibility via the ANS website, please contact ANS at 800.417.6693, extension 234, or via e-mail at:

[email protected]

Please note that due to possible eligibility status changes, the information provided by either system does not guarantee payment. If you are having difficulty accessing either the IVR or websites, please contact the Customer Service Department at 888.875.7482. They will be able to assist you in utilizing either system.

1.04 KidCare Program Copayments

Eligibility cards authorizing services are issued in generally the same manner as the MediPlan Card, except that the KidCare card is canary yellow in color. The card will indicate KidCare and will be issued on a monthly basis. Some Participants will have copayment responsibilities. Copayment amounts will be noted on the eligibility card. The copayment amount is in addition to state reimbursement for the procedure and is collected at the dentist’s discretion. If the family has reached the maximum, it will be printed on the eligibility card (or the Participant may have a written notice stating this) and no copayment should be collected.

Please Note: No copayments may be charged for routine preventive and diagnostic dental services including oral examinations, oral prophylaxis, fluoride treatments, sealants and x-rays.

Dental services provided under KidCare will be reimbursed at the same rates as for Medicaid recipients. Providers will keep copayments they collect. Claims for these services are to be submitted to Doral Dental Services of Illinois, LLC.

1.05 Expanded Dental Services for Certain Participants

In addition to the normal Medical Assistance Dental Program services, certain Participants qualify for dental services not covered through the Medical Assistance Dental Program. These dental services are covered as part of a Supportive Services program managed through the Department of Human Services (DHS) to treat conditions that are a barrier to employment. The DHS caseworker may contact Doral or refer the Participant to a dentist enrolled in the Dental Program for consultation of whether the necessary dental services are covered under the Dental Program.

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http://www.anslink.net/

http://www.anslink.net/



To be eligible for these services the Participant must obtain a written description of the required dental service and cost estimate. The dentist’s statement must also include the dentist’s name, address, phone number, dental license number, Social Security number or FEIN, fees and dentist’s signature. The DHS Local Office Administrator makes the decision to approve or deny the dental services. The Participant and the dentist are notified of the decision (Form 1934). Once the dental work has been completed, the dentist bills the local DHS office at the address listed on the approval memo and includes the approval forms with the dentist’s statement. The dentist will receive payment at the maximum allowable Medical Assistance Dental Program rate or the actual charge, whichever is less. Payments are usually made within 30 days of the receipt of the claim at the Springfield Central Office. Information on the status of the payment should be directed to the DHS caseworker.

1.06 Consent Process for DCFS Wards

There are two types of consent for DCFS wards related to dental care -- one for ordinary and routine medical and dental care and one for medical/surgical treatment. Caregivers for DCFS wards do not have the authority to provide consent; such consent must be provided by the DCFS Guardianship Administrator or an authorized agent. As a general rule, DCFS and private agency caseworkers should be the contact for obtaining a consent. If you have not been given a signed consent for providing care to a DCFS ward, please speak with the child's caseworker (or have the foster parent speak with the caseworker) about the need for a signed consent appropriate for the type of care being provided. For a consent involving medical/surgical treatment, please be prepared to give detailed information upon request regarding the procedure, including its risks and benefits. However, if a child arrives for dental care on a weekday (between 8:30 AM and 5:00 PM) and you do not have a consent, please contact the DCFS Consent Unit at 800.828.2179 for assistance. The Consent Unit can coordinate obtaining a consent so that the appointment does not have to be rescheduled. If urgent treatment is required during weekends, holidays and after regular office hours, please call DCFS at 773.989.3450 or 217.782.6533 to obtain a consent.

1.07 Doral Customer Service Numbers

Doral offers Customer Service for Providers at 888.281.2076.

Doral offers Customer Service for Participants at 888.286.2447. Doral offers TTY service for hearing impaired Participants at 800.466.7566.

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2.00 Covered Benefits

Please refer to the following attachments for a complete list of covered benefits:

Coverage Attachment Children Q Adult R

This section identifies program benefits and clearly defines individual age and benefit limitations, exclusions and special documentation requirements.

Medical Assistance Participants are to be allowed the same access to dental treatment as any other patient in the dental practice. Enrolled Participating Providers are not allowed to charge Participants for missed appointments. Pursuant to Section 140.12(h) of the Illinois Administrative Code, payment made must be accepted as payment in full for covered services. Private reimbursement arrangements may be made only for non-covered services.

Missed Appointments

If your office mails letters to Participants who miss appointments, the following language may be helpful to include:

• “We missed you when you did not come for your dental appointment on

month/date. Regular check-ups are needed to keep your teeth healthy.” • “Please call to reschedule another appointment. Call us ahead of time if you

cannot keep the appointment. Missed appointments are very costly to us. Thank you for your help.”

Doral offers the following suggestions to decrease the number of missed appointments.

• Contact the Participant by phone or postcard prior to the appointment to remind

the individual of the time and place of the appointment. • If the appointment is made through another state agency such as DCFS, DSCC

or DHS contact staff from that program to ensure the scheduled appointment is kept.

The Centers for Medicare and Medicaid Services (CMS) interpret federal law to prohibit a provider from billing a Medicaid Participant for a missed appointment. In addition, your missed appointment policy for Medicaid patients cannot be stricter than that of your private or commercial patients. If a Medicaid patient exceeds your office policy for missed appointments and you choose to discontinue seeing the patient, please inform them to contact Doral for a referral to a new dentist. Providers with benefit questions should contact Doral’s Customer Service Department directly at:

888.281.2076

Doral recognizes tooth letters “A” through “T” for primary teeth and tooth numbers “1” to “32” for permanent teeth (see Attachment L). Supernumerary teeth should be designated by using codes AS through TS or 51 through 82. Designation of the tooth can be determined by using the nearest erupted tooth. If the tooth closest to the supernumerary tooth is # 1 then the

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supernumerary tooth should be charted as #51, likewise if the nearest tooth is A the supernumerary tooth should be charted as AS. These procedure codes must be referenced in the patient’s file for record retention and review. Patient records must be kept for a minimum of 7 years and must be available in a paper form for at least the first two years. All dental services performed must be recorded in the patient record, which must be available as required by your Participating Provider Agreement.

For reimbursement, Enrolled Participating Providers should bill only per unique surface regardless of locations. For example, when a dentist places separate fillings in both occlusal pits on an upper permanent first molar, the billing should state a one surface occlusal amalgam ADA procedure code D2140. Furthermore, Doral will reimburse for the total number of surfaces restored per tooth, per day; (i.e. a separate occlusal and buccal restoration on tooth 30 will be reimbursed as 1 (OB) two surface restoration). When submitting claims, always indicate your billed charges. The HFS and Doral will reimburse you for approved covered services at the lesser of your billed charges or the approved HFS fee.

The Doral claim system can only recognize dental services described using the current American Dental Association CDT code list or procedure codes as defined by Healthcare and Family Services. All other procedure codes not contained in the following tables will be rejected when submitted for payment. A complete copy of the current CDT book can be purchased from the American Dental Association at the following address:

American Dental Association

211 East Chicago Avenue Chicago, IL 60611

800.947.4746

The guidelines in the benefit tables are all-inclusive for covered services and conform to generally accepted standards of dental practice. Each category of service is contained in a separate table and lists:

• the approved procedure code to submit when billing, • a brief description of the covered service, • any age limits imposed on coverage, • a description of documentation, in addition to a completed claim form, that must

be submitted when a claim or request for prior authorization is submitted, • an indicator of whether or not the service is subject to prior authorization, and • any other applicable benefit limitations.

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2.01 Payment for Non-Covered Services

Enrolled Participating Providers shall hold Participants, Doral, and Healthcare and Family Services harmless for the payment of non-Covered Services except as provided in this paragraph. Provider may bill a Participant for non-Covered Services if the Provider obtains an agreement from the Participant prior to rendering such service that indicates:

• the services to be provided; • Doral and Healthcare and Family Services will not pay for or be liable for said Services; and • Participant will be financially liable for such services.

Doral encourages Enrolled Participating Providers to obtain this agreement in writing when possible.

2.02 Electronic Attachments

A. FastAttach™ - Doral accepts dental radiographs electronically via FastAttach™ for authorization requests. Doral, in conjunction with National Electronic Attachment, Inc. (NEA), allows Enrolled Participating Providers the opportunity to submit all claims electronically, even those that require attachments. This program allows transmissions via secure Internet lines for radiographs, periodontic charts, intraoral pictures, narratives and EOBs.

FastAttach™ is inexpensive and easy to use, reduces administrative costs, eliminates lost or damaged attachments and accelerates claims and prior authorization processing. It is compatible with most claims clearinghouse or practice management systems.

For more information or to sign up for FastAttach go to www.nea-fast.com or call NEA at 800.782.5150.

B. OrthoCAD™ - Doral accepts orthodontic models electronically via OrthoCAD™

for authorization requests. Doral allows Enrolled Participating Providers the opportunity to submit all orthodontic models electronically. This program allows transmissions via secure Internet lines for orthodontic models. OrthoCAD™ is inexpensive and easy to use, reduces administrative costs, eliminates lost or damaged models and accelerates claims and prior authorization processing. It is compatible with most claims clearinghouse or practice management systems.

For more information or to sign up for OrthoCAD™ go to www.orthocad.com or call OrthoCAD™ at 800.577.8767.

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http://www.nea-fast.com/

http://www.orthocad.com/


3.00 Prior Authorization, Retrospective Review, and Documentation Requirements

Doral Dental Services of Illinois, LLC, must make a decision on a request for prior authorization within thirty (30) days from the date Doral receives this request, provided all information is complete. If Doral does not decide on this request and send the recipient written notice of its decision on the services requested on this statement within thirty (30) days, the request will automatically be approved. If Doral denies the approval for some or all of the services requested, Doral will send the recipient a written notice of the reasons why, and will tell the recipient that he or she may appeal the decision. Within fourteen (14) days of a receipt of a prior authorization or a retrospective review request, that in the opinion of Doral requires additional information, Doral will notify the provider submitting the request that additional information is necessary. Doral must be provided with information/documentation sufficient to show necessity in order to approve a prior authorization or a retrospective review. The additional information sought may include, but is not limited to additional Participant/patient information, additional procedure information or additional diagnostic information necessary to process or review the prior authorization. Procedures Requiring Prior Authorization Doral has specific dental utilization criteria as well as a prior authorization and retrospective review process to manage the utilization of services. Consequently, Doral’s operational focus is on assuring compliance with its dental utilization criteria. One method used on a limited basis to assure compliance is to require providers to supply specified documentation prior to authorizing payment for certain procedures. Services that require prior authorization should not be started prior to the determination of coverage (approval or denial of the prior authorization) for non-emergency services. Non-emergency treatment started prior to the determination of coverage will be performed at the financial risk of the dental office. If coverage is denied, the treating dentist will be financially responsible and may not balance bill the Participant, the State of Illinois or any agents, and/or Doral. Prior authorizations will be honored for 120 days from the date they are issued. An approval does not guarantee payment. The Participant must be eligible at the time the services are provided. Provider should verify eligibility at the time of service. Requests for prior authorization should be sent with the appropriate documentation on a standard ADA approved claim form. The tables of covered services, Attachments Q and R, contain a column marked Prior Authorization Required. A “Yes” in this column indicates that the service listed requires prior authorization to be considered for reimbursement. There is also a column that indicates what documentation, in addition to the completed claim form, needs to be submitted for consideration. Any claims or Prior Authorizations submitted without the required documentation will be denied and must be resubmitted to obtain reimbursement. The basis for granting or denying approval shall be whether the item or service is medically necessary, whether a less expensive service would adequately meet the Participant’s needs, and whether the proposed item or service conforms to commonly accepted standards in the dental community. During the prior authorization process it may become necessary to have your patient clinically evaluated. If this is the case, you will be notified of a date and time for the examination. It is the

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responsibility of the participating dentist to ensure attendance at this appointment. Patient failure to keep an appointment will result in denial of the treatment.

Retrospective Review Services that would normally require a Prior Authorization, but are performed in an emergency situation, will be subject to a Retrospective Review. These claims should be submitted to the address utilized when submitting services for Prior Authorization, accompanied by any required documentation. Any claims or Retrospective Review submitted without the required documents will be denied and must be resubmitted to obtain reimbursement. After the Doral Consultant reviews the documentation, an authorization number will be provided to the submitting office for their records. This authorization number will normally be provided within ten business days from the date the documentation is received. For emergency services submitted for retrospective review, a number will be assigned, and the claim will be forwarded for payment. The office will receive a Prior Authorization document, but no further submission is necessary for payment.

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4.00 Dental Services in a Hospital Setting

Effective January 1, 2005, dentists will no longer have to obtain prior approval for dental procedures performed in a hospital outpatient setting or an Ambulatory Surgical Treatment Center (ASTC). All dental procedures performed in these outpatient settings will be subject to post payment review by the department’s peer review organization. Patient Criteria Specific criteria must be met in order to justify the medical necessity of performing a dental procedure in the outpatient setting. The criteria are:

• The patient requires general anesthesia or conscious sedation. • The patient has a medical condition that places the patient at an increased surgical risk,

such as, but not limited to: cardio-pulmonary disease, congenital anomalies, history of complications associated with anesthesia, such as hyperthermia or allergic reaction, or bleeding diathesis; or

• Patient cannot safely be managed in an office setting because of a behavioral, developmental or mental disorder.

Dental Billing Procedures

• Claims must include documentation to support the medical necessity for performing the procedure in the outpatient setting including a narrative specifying the medical necessity, supporting x-rays and any other explanation necessary to make a determination.

• Dentists must record a narrative of the dental procedure performed and the corresponding CDT/HCPCS dental codes in the patient’s medical record at the outpatient setting. If the specific dental code is unknown, the code D9999 may be used.

• Claims must be submitted to Doral for the covered professional services in the same format and manner as all standard dental procedures.

Hospital/ASTC Billing Procedures The hospital or ASTC will bill the department on a UB-92 form for the all-inclusive rate for facility services using the assigned CDT/HCPCS dental code. The hospital must have this code in order to be paid for the facility services. The applicable dental codes will result in payment to hospital/ASTC for the Ambulatory Procedures Listing (APL) Group 1d – Surgical Procedures/Very Low Intensity. All facility bills for services performed in the outpatient setting should be forwarded to: Healthcare and Family Services P.O. Box 19132 Springfield, Illinois 62763 Participating Hospitals/ASTCs Dentists must administer the services at a hospital or ASTC that is enrolled in the Illinois Medical Assistance Program. Questions regarding hospital participation should be directed to the Bureau of Comprehensive Health Services at 217-782-5565.

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5.00 Claim Submission Procedures (claim filing options) Doral receives dental claims in four possible formats. These formats include:

• Electronic claims via Doral’s website (www.doralusa.com) • Electronic submission via clearinghouses • HIPAA Compliant 837D File • Paper claims

5.01 Electronic Claim Submission Utilizing Doral’s Internet Website

Enrolled Participating Providers may submit claims directly to Doral by utilizing the “Provider’s Only” section of our website. Submitting claims via the website is very quick and easy. It is especially easy if you have already accessed the site to check a Participant’s eligibility prior to providing the service. To submit claims via the website, simply log on to www.doralusa.com. Once you have entered the website, click on “Doral Dental USA”, and then click on “For Providers Only.” You will then be able to log in using your password and ID. First time users will have to register by utilizing their Doral 6 digit Location ID prior to logging in. Once logged in, select “enter a claim now” and enter the Participant’s applicable information in the field provided. It is NOT necessary to enter the Participant’s last name and/or first initial; only the identification number, date of birth, and date of service are required. Next you will click on the word “before” that appears below the Participant’s DOB field to verify eligibility and populate the name fields automatically. Once this information is generated you may now begin to enter the claim line detail to complete the submission. If you have questions on submitting claims or accessing the website, please contact our Systems Operations Department at 888.560.8135 or via e-mail at:

[email protected]

5.02 Electronic Claim Submission via Affiliated Network Services (ANS)

Enrolled Participating Providers may also submit claims to Doral through the ANS’ website at [email protected]. Submitting claims via the website is very quick and easy. It is especially easy if you have already accessed the site to check a Participant’s eligibility prior to providing the service. When online, type [email protected] into the web browser. This will take you to the screen that allows you to enter the ANSLink® system. After pressing the enter button, the log-in screen will appear. If the office signing-in has a user ID and password, that information is entered in the appropriate spaces. If it is the first time for an office using the system, the ”NEW OFFICE” button is selected, which will take the user through a step-by-step registration process to gain access into ANSLink®.

If you have questions on verifying eligibility via the website, please contact ANS at 800.417.6693, extension 234 or via e-mail at:

[email protected]

5.03 Electronic Claim Submission via Clearinghouse

Dentists may submit their claims to Doral via Affiliated Network Services (ANS), EMDEON or Lindsay Consulting. Doral’s current relationship with ANS offers FREE transmission for ALL Doral Dental claims. Additional clearinghouses may be added in the future.

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http://[email protected]/



You can contact your software vendor and make certain that they have Doral listed as a payer. Your software vendor will be able to provide you with any information you may need to ensure that submitted claims are forwarded to Doral.

5.04 HIPAA Compliant 837D File

For Providers who are unable to submit electronically via the Internet or a clearinghouse, Doral will, on a case by case basis, work with the Provider to receive their claims electronically via a HIPAA Compliant 837D file from the Provider’s practice management system. Please contact the Systems Operations Department at 888.560.8135 or via e-mail at [email protected] to inquire about this option for electronic claim submission.

5.05 Paper Claim Submission Claims must be submitted on ADA approved claim forms or other forms approved in advance by Doral. Please see Attachment C for a sample claim form and completion instructions. Forms are available through the American Dental Association at:

American Dental Association 211 East Chicago Avenue

Chicago, IL 60611 800.947.4746

Participant name, identification number, and date of birth must be listed on all claims submitted. If the Participant identification number is missing or miscoded on the claim form, the patient cannot be identified. This could result in the claim being returned to the submitting Provider office, causing a delay in payment.

The Provider and office location information must be clearly identified on the claim. Frequently, if only the dentist signature is used for identification, the dentist’s name cannot be clearly identified. Please include either a typed dentist (practice) name or the Doral Provider identification number.

The date of service must be provided on the claim form for each service line submitted. Approved ADA dental codes as published in the current CDT book or as defined in this manual must be used to define all services.

List all quadrants, tooth numbers and surfaces for dental codes that necessitate identification (extractions, root canals, amalgams and resin fillings). Missing tooth and surface identification codes can result in the delay or denial of claim payment.

Affix the proper postage when mailing bulk documentation. Doral does not accept postage due mail. This mail will be returned to the sender and will result in delay of payment.

Claims should be mailed to the following address:

DDS of Illinois - Claims

12121 N. Corporate Parkway Mequon, WI 53092

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6.00 Inquiries, Complaints and Appeals Doral Dental Services of Illinois, LLC, is committed to providing high quality dental services to all Participants. As part of this commitment, Doral supports a complaints and appeals protocol that assures that all Participants have every opportunity to exercise their rights to a fair and expeditious resolution to any and all inquiries, complaints and appeals. Towards that end, Doral has developed a procedure to meet the following goals:

• To ensure that Participants receive a fair, just and speedy resolution to inquiries,

complaints and appeals. • To allow Participants to be treated with dignity and respect at all levels of the

complaints and appeals resolution process. • To inform Participants of their full rights as they relate to complaints and appeals

resolution, including their rights of appeal at each step in the process. • To have Participant complaints and appeals resolved in a satisfactory and

acceptable manner within the Doral protocol. • To comply with all regulatory guidelines and policies with respect to Participant

inquiries, complaints and appeals. • To efficiently track the resolution of provider related complaints, so as to be able

to track continuing unacceptable patterns of care over time.

Doral Dental Services of Illinois, LLC provides customer services, the primary purpose of which is to insure Participant access to information, services, and assistance on issues affecting their coverage. The designated complaint coordinator is dedicated to the expedient, satisfactory resolution of Participant inquiries, complaints and appeals. Inquiry

An inquiry is any Participant request for administrative service or information, or an expression of an opinion regarding services or benefits available under the Dental Program. Customer Service Representatives are trained to respond in a prompt and courteous fashion, and to resolve any surrounding issues in an expedient manner. Customer Service Representatives have at their disposal all internal resources of Doral to insure prompt resolution of any problems. If specific corrective action is requested by the Participant or determined to be necessary by Doral, then the inquiry is upgraded to complaint.

Complaints

A complaint is any issue a Participant presents to Doral either orally or written, which is subject to informal resolution by panel within a 30-day period. Doral uses the following approach to resolve all Participant complaints within a 30-day period:

A. When a complaint is received by any representative of Customer Services, either orally

or in writing, it will be forwarded to the Doral Complaint Representative as quickly as possible.

B. The Complaint Representative will then assign the appropriate trending code and will

make every effort to resolve the complaint on an immediate basis, (within 24 hours whenever possible). The Complaint Representative will handle the complaints themselves, or identify the appropriate Doral personnel, and forward the complaint to that department requesting resolution within three days. The Complaint Representative will do appropriate follow-up as needed to ensure expedient handling and to keep the Participant informed as to the stage of investigation and resolution.

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C. If the Participant chooses to appeal the decision, the Customer Services Representative

will assist them by providing the information on how to initiate the appeals process. D. For any complaints involving a provider, a copy of the complaint and all attachments will

be forwarded to the Credentialing Department and placed in the provider file. E. The toll free number to call to file a complaint is:

1.888.875.7482

F. The address to file a complaint is:


Complaint Representative 12121 North Corporate Parkway

Mequon, WI 53092

Appeals

A. Participant Appeals

The Illinois Department of Human Services will help Participants file an appeal concerning the denial of benefits under the Dental Program. Participants must file an appeal within 60 days following the date the denial letter was mailed by Doral. Participants can ask for a hearing by calling the Fair Hearings Section at 1.800.435.0774 (TTY: 312.793.2697 or 800.526.0857) or by writing to Healthcare and Family Services, Bureau of Administrative Hearings, 401 South Clinton Street, 6th floor, Chicago, IL 60607. Participants may also contact their caseworker for information concerning appeals. A Participant may appeal any Doral decision that denies or reduces services. Such appeal will be reviewed by Healthcare and Family Services under its existing administrative appeal procedure.

Once Healthcare and Family Services is notified, they will forward a request for additional information to Doral. Doral will have seven (7) days to provide the hearing office with a report of the incident cited. The matter will be heard before an Administrative Hearing Officer. Doral will provide and pay for any services which the Department or any Court of any jurisdiction orders rendered, provided the Participant is eligible.

Doral assists the Department in preparing for dental appeals and shall make expert testimony available.

B. Dentist Appeal Procedures

In the operation of the Doral program, differences may develop between Doral and the dentist concerning the decision regarding the Prior Authorization Option and payment for service. Since many of these problems result from misunderstanding of processing policy, service coverage or payment levels, thorough acquaintance with Doral will help prevent such problems. Doral provides the following mechanism for resolving these differences.

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To request reconsideration the doctor may call or write:

Doral Dental Services of Illinois, LLC 12121 North Corporate Parkway

Mequon, WI 53092 888.281.2076

Fax 262.241.7401

If the problem cannot be resolved at this level, the dentist shall be requested to submit his appeal for reevaluation in writing.

C. Request for Reevaluation

The provider’s request for reevaluation must be in writing with complete documentation that includes identifying the Attending Dentist’s Statements and specifically describes the disputed action or inaction. If the request refers to an action by a Doral Dental Consultant, the request will be considered by the Reevaluation Committee. This committee shall make a decision based upon the available information, Doral processing policies, and applicable state regulation, or they may refer the problem to a regional consultant (a practicing dentist who has been selected by Doral on the recommendation of a component dental society) for review and recommendation. The Doral Reevaluation Committee shall make a final review of the request based on all information obtained and send a written report of the conclusion to the dentist within 60 days of the acknowledgement of receipt of all required information.

D. Quality Control/Peer Review

Doral has formed a Peer Review Committee composed of the Doral Dental Director, HFS dental consultants, and a minimum of five participating dentists that submit at least 25 Medical Assistance claims per year. The Committee evaluates the operational procedures and policies as they affect the administration of the Medical Assistance Dental Program. In addition, the Committee is involved in reviewing Attending Dentists Statements with respect to pre-treatment estimates and actual services rendered. Finally, the Peer Review committee is responsible for evaluating the care provided under this program. Various methods are used to identify those dentists whose services do not conform to standards deemed acceptable by Doral. Claim forms, analysis of Participant complaints, utilization of certain procedures or excessive treatment will identify those providers who are delivering services to Participants when those services may not be in the best interest of the dental health of the Participant. The goal of the Peer Review Committee is to provide guidelines for the assessment of clinical quality and professional performance as well as guidelines for reviewing services provided by dentists. By communicating problem areas to the dentist, Doral shall provide a framework for correction so that questionable practice patterns may be eliminated. Thus, Doral’s program is geared to take corrective action before abuses in the system affect the Participant.

The data from the claim forms shall be entered into Doral’s computer system to permit assessment of treatment plans as well as the quality of care. To that end, Doral plans to conduct various dental evaluation studies during the course of each year to address a clinical problem or diagnostic category and from its findings, recommend changes in the program. Thereafter, a follow-up study shall be done to assess the effect of any program changes.

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E. Quality Improvement/Utilization Management (QI/UM) Committee

The purpose of the QI/UM Committee is to review data; to assess and evaluate utilization patterns; to advise the Department on dental services policy; recommend professional education to correct identified utilization problems; and to refer to the Peer Review Committee any quality of service care issues identified during utilization review.

6.01 Receipt and Audit of Claims

In order to ensure timely, accurate remittances to each dentist, Doral performs an edit of all claims upon receipt. This edit validates Participant eligibility, procedure codes and provider identifying information. A Regional Benefit Analyst dedicated to Illinois dental offices analyzes any claim conditions that would result in non-payment. When potential problems are identified, your office may be contacted and asked to assist in resolving this problem. Please feel free to contact Doral’s Provider Relations Department at 888.281.2076 with any questions you may have regarding claim submission or your remittance. Each Enrolled Participating Provider office receives an “explanation of benefit” report with their remittance. This report includes Participant information and an allowable fee by date of service for each service rendered during the period. If a dentist wishes to appeal any reimbursement decision, they need to submit an appeal in writing, along with any necessary additional documentation within 60 days to:

Doral Dental Services of Illinois, LLC APPEALS

12121 North Corporate Parkway Mequon, WI 53092

Doral will have 30 days to respond in writing to the dentist with outcome of the appeal. This notice will contain the information necessary to appeal this decision. To validate accuracy, on a monthly basis Doral will perform an audit of a statistically significant sample of all the claim forms entered and adjudicated in the prior month.

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7.00 Health Insurance Portability and Accountability Act (HIPAA)

As a healthcare provider, if you transmit any health information electronically your office is required to comply with all aspects of the HIPAA regulations that have gone/will go into effect as indicated in the final publications of the various rules covered by HIPAA. The compliance dates for the various HIPAA rules are as follows:

• Privacy Standards – April 14, 2003 • Administrative Simplification Standards – October 16, 2003 (If you filed for the one

year extension beyond the initial October 16, 2002 date). • Security Standards – April 21, 2005

Doral has implemented various operational policies and procedures to ensure that it is compliant with the Privacy Standards as well. Doral also intends to comply with all Administrative Simplification and Security Standards by their compliance dates. One aspect of our compliance plan will be working cooperatively with providers to comply with the HIPAA regulations.

Provider and Doral agree to conduct their respective activities in accordance with the applicable provisions of HIPAA and such implementing regulations.

In relation to the Administrative Simplification Standards, you will note that the benefit tables included in this ORM reflect the most current coding standards (CDT-5) recognized by the ADA. Effective the date of this manual, Doral will require providers to submit all claims with the proper CDT-5 codes listed in this manual. In addition, all paper claims must be submitted on the current approved ADA claim form.

Note: Copies of Doral’s HIPAA policies are available upon request by contacting Doral’s Customer Service department at 888.281.2076 or via e-mail at [email protected].

Please refer to Attachment E of this manual for Doral’s Companion Guide for 837 Health Care Claim Transactions.

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8.00 Utilization Management Program

8.01 Introduction

Reimbursement to dentists for dental treatment rendered can come from any number of sources such as individuals, employers, insurance companies and local, state or federal government. The source of dollars varies depending on the particular program. For example, in traditional insurance, the dentist reimbursement is composed of an insurance payment and a patient coinsurance payment. The Illinois State Legislature annually appropriates or “budgets” the amount of dollars available for reimbursement to dentists for treating Illinois Medical Assistance Participants. Since there is usually no patient co-payment, these dollars represent all the reimbursement available to the dentist. The fair and appropriate distribution of these limited funds is critical.

8.02 Community Practice Patterns

To ensure fair and appropriate reimbursement, Doral has developed a philosophy of Utilization Management that recognizes the fact that there exists, as in all healthcare services, a relationship between the dentist’s treatment planning, treatment costs and treatment outcomes. The dynamics of these relationships, in any region, are reflected by the “community practice patterns” of local dentists and their peers. With this in mind, Doral’s Utilization Management Programs are designed to ensure the fair and appropriate distribution of healthcare dollars as defined by the regionally based community practice patterns of local dentists and their peers.

All utilization management analysis, evaluations and outcomes are related to these patterns. Doral’s Utilization Management Programs recognize that there is individual dentist variance within these patterns among a community of dentists and accounts for such variance. Also, specialty dentists are evaluated as a separate group and not with general dentists since the types and nature of treatment may differ.

8.03 Evaluation

Doral’s Utilization Management Programs evaluate claims submissions in such areas as:

• Diagnostic and preventive treatment; • Patient treatment planning and sequencing; • Types of treatment; • Treatment outcomes; and • Treatment cost effectiveness.

8.04 Results

With the objective of ensuring the fair and appropriate distribution of these “budgeted” Medical Assistance Dental Program dollars to dentists; Doral’s Utilization Management Programs helps identify dentists whose patterns show significant deviation from the normal practice patterns of the community of their peers (typically less than 5% of all dentists). Doral is contractually obligated to report suspected fraud, abuse or misuse by Participants and Participating Dental Providers to the Healthcare and Family Service’s Office of the Inspector General.

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8.05 Fraud and Abuse

Doral is committed to detecting, reporting and preventing potential fraud and abuse. Fraud and abuse are defined as:

Fraud: Intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under federal or state law. Abuse: Intentional infliction of physical harm, injury caused by negligent acts or omissions, unreasonable confinement, sexual abuse or sexual assault. Provider Fraud: Provider practices that are inconsistent with sound fiscal, business or medical practices, and result in unnecessary cost to the program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the program. Doral is contractually obligated to report suspected fraud, abuse or misuse by Participants and Participating Dental Providers to Healthcare and Family Services Office of Inspector General and/or the Illinois Department of Financial and Professional Regulation.

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9.00 Quality Improvement Program (Policies - 200 Series)

Doral currently administers a Quality Improvement Program modeled after National Committee for Quality Assurance (NCQA) standards. The NCQA standards are adhered to because these standards apply to dental managed care. The Quality Improvement Program includes:

• Participant satisfaction surveys • Provider satisfaction surveys • Complaint Monitoring and Trending • Peer Review Process • Utilization Management and practice patterns • Quarterly Quality Indicator tracking

A copy of Doral’s Quality Improvement Program is available upon request by contacting Doral’s Customer Service Department at 888.281.2076 or via e-mail at:

[email protected].

In establishing criteria for quality dental care and making these characteristics of quality care the standard for review, two types of criteria are involved in developing standards. One type of criteria is explicit in nature and is delineated in the written form of Participant treatment protocol and utilization guidelines. The second type of criteria is implicit in nature and based on health care procedures and practices which are “commonly understood” to be acceptable and consistent with the provision of good quality care.

• Comparing the care that has actually been rendered with the criteria.

• Making a peer judgment on quality based on the results of the comparison.

As stated previously, Quality Assurance goes beyond measurement and involves the implementation of any necessary changes to maintain and improve the quality of care being delivered including:

• Acting on the result of the evaluation by taking corrective action on any

deficiencies noted. • Assuring that the actions have favorable impact by raising the standards for

the dental care delivered. The purpose of the Quality Improvement Program is to evaluate the quality of dental care being delivered to Doral Participants. The goals of the program are to:

• Support the delivery of the highest quality of dental care by the participating dental offices, the primary objective is the Participant’s health and welfare.

• Identify any areas of the dental practice that need improvement. • Provide ongoing feedback to the participating dentists and auxiliary staff. • Analyze statistical data to assure efficient utilization.

The Quality Improvement Program will utilize accepted standards, guidelines and protocols which have been developed by the Federal Government, American Academy of Dental Group Practice, the American Dental Association, the American Academy of Pediatric Dentistry, various State Dental Associations and specialty groups.

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10.00 Preventive Dental Services Provided Out-of-Office

Preventive services allowed to be provided in an out-of-office setting include:

• D0120- Periodic Oral Examination • D1120- Prophylaxis – Child • D1203- Topical Application of Fluoride (excluding prophylaxis) – Child • D1351- Sealant – Per Tooth

When filing a claim for preventive services performed out-of-office, designate the place of service as follows:

• For paper claims, mark the “other” box in the place of service field, #38 and, if applicable, put

the name of the school where services were performed in the remarks field, #35. • For electronic claims, in the place of service field, type 03 for school, or 15 for other.

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060101-IL A-1

ATTACHMENT A

General Definitions

The following definitions apply to this Dental Office Reference Manual:

A. “Covered Services” is a dental service or supply that satisfies all of the following criteria:

• provided by an Enrolled Participating Provider to a Participant; • authorized by Doral in accordance with the Provider’s Certificate of

Coverage; and • submitted to Doral according to Doral’s filing requirements.

B. “Doral” shall refer to Doral Dental Services of Illinois, LLC. C. “Enrolled Participating Provider” is a dental professional or facility or other entity that

has entered into a written agreement with Healthcare and Family Services (HFS) through Doral to provide dental services. Any dentist providing services to Participants of a HFS Medical Assistance Program is required to be enrolled with the Department (89 IL ADC 140.23). The provider of service must bill as the treating dentist. The provider of service may elect to be his/her own payee or identify an alternate payee.

D. “Medical Assistance Dental Program” means dental program administered by

Healthcare and Family Services for Medicaid and KidCare Participants. E. “Medically Necessary” means those Covered Services provided by a physician or other

licensed practitioner of the healing arts within the scope of their practice under State law to prevent disease, disability and other adverse health conditions or their progression, or prolong life. In order to be Medically Necessary, the service or supply for medical illness or injury must be determined by Plan or its designee in its judgement to be a Covered Service which is required and appropriate in accordance with the law, regulations, guidelines and accepted standards of medical practice in the community.

F. “Participant” means any individual who is enrolled in the Illinois Medicaid or KidCare

program.


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ATTACHMENT B

1. Control Area Not relevant.

2 Case ID Number

The case identification number identifies the specific case or family unit in which all Participants listed on the card are included. The case identification number may be used by the provider as a reference when contacting the Department, the local DHS office or the regional DCFS office. This number is not to be used by the provider on billing documents.

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3 Eligibility/Coverage Period

The dates listed in this section are the inclusive beginning and end dates of the coverage period documented by the card. Coverage for periods before or after the dates on the card can be verified by contacting Doral’s Provider Relations Department at 1.888.875.7482.

4 Case Names and Address

The case name appears in conjunction with the mailing address. It is the main identifier associated with the case identification number. The individual whose name appears as the case name is not eligible for medical services unless the name also is shown in the listing of “eligible persons” on the back of the card. In instances in which a second individual, a bank, an agency or an institution has been designated as guardian, protective payee or representative payee, the applicable name and identifying initials will appear as part of the mailing address.

5 Messages

A variety of explanatory messages may appear in this area. They include such subjects as allowable co-payments and benefit restrictions for certain programs. See 1.01 for limited benefit programs relevant to the Medical Assistance Dental Program.

6 Special Limitations

Not relevant.

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1 Items Repeated from the Front of the Card

The Eligibility/Coverage Period, Case ID Number and Case Name and Address which appear on the front of the card also appear in the three boxes on the back of the card.

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2 Name of Covered Participants

The first column in this area shows the name of every covered Participant in the case. The order of the name is first name, middle initial and last name. The name, exactly as shown on the card, of the person to whom services were rendered should be entered as the patient name on the provider’s claim.

3 Recipient Identification Number (RIN)

To the right of each covered person’s name is the unique, nine-digit Recipient Identification Number for that individual. Each number is valid for only one person. Because this identification number is used to verify eligibility, it is essential that the provider take extreme care when entering the number on the billing form. Use of incorrect numbers is a common cause of billing rejections. It is imperative that the specific number for the patient to whom the medical service was rendered be used on HFS billing forms and on Medicare billing forms if they are expected to electronically cross over to HFS.

4 Date of Birth

The individual’s complete birth date appears in the next column. Its form is month (two digits), day (two digits) and year (two digits).

5 Medicare Coverage

The next column to the right identifies Medicare coverage of the individual. An entry will appear in this column only if the Participant has Medicare coverage. If the space in this column is blank, it indicates that neither DHS nor HFS is aware of Medicare eligibility. This does not eliminate the provider’s responsibility to inquire about such coverage. The codes which may appear in this column are listed below with the type of coverage:

CODE TYPE OF COVERAGE PART A HOSPITAL INSURANCE PART B MEDICAL INSURANCE PART AB BOTH OF THE ABOVE

6 TPL

The last column of each line will identify, by code, known third party resources. Information entered here will refer to the Department’s record of such resources. The TPL resource code will consist of a three-digit numeric code that may be prefixed with an alphabetic coverage code. The three-digit resource code identifies a specific health insurance company or union fund. The alpha coverage code, if present, indicates the extent of coverage provided by the resource.

EXAMPLE: A Participant who is insured under a health plan by Aetna Life Insurance Company will have “001" printed in the TPL column of the MediPlan card. The addition of the prefix “A” (A001) will indicate the Participant has a “comprehensive” health plan underwritten by Aetna. For an explanation of the TPL codes which may appear on the MediPlan Card, refer to General Appendix 9, Third Party Liability Resource Codes, of the Department’s Handbook for Providers of Medical Services.

The lack of a code in this space means that the Department is not aware of any TPL coverage. It does not eliminate the provider’s responsibility to inquire about the possibility of such coverage.

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7 Total Person

The total number of persons listed in this line should always match the number of individual Participants listed above the line.

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ATTACHMENT D

Malocclusion Severity Assessment By J.A. Salzmann, DDS, F.A.P.H.A.

Participant Name: _________________________________________________ Date of Birth: Case Name: ______________________________________________________ Dentist’s Name: Examiner: _______________________________________________________ Date: Records Received:

Intra-Oral Photos Photos Models CEPH PANO X-Rays Fees Intra

Quality:

Intra-Oral Photos Photos Models CEPH PANO X-Rays Fees Intra

A. INTRA-ARCH DEVIATION

Score Teeth Affected Only Missing Crowded Rotated Spacing

Open Spacing Closed No. Point

Value Score

Ant X2 Maxilla Post X1

Ant X1 Mandible Post 0 X1

Total Score

Ant = anterior teeth (4 incisors) Post. = posterior teeth (Include canine, premolars and first molar). No. = number of teeth affected P.V. = point value

B. Inter-Arch Deviation 1. Anterior Segment

Overjet Overbite Crossbite Openbite No. P.V. Score Score Maxillary Teeth

Affected Only Except Overbite* X2

Total Score

*Score maxillary or mandibular incisors. 2. Posterior Segment

Score Teeth Affected Only Related Mandibular to Maxillary Teeth

Score Affected Maxillary Teeth Only No. P.V. Score

Distal Mesial Crossbite Openbite

Right Left Right Left Right Left Right Left Canine

1st Premolar

2nd Premolar

1st Molar

Total Score Add 8 points when intra-and intra-arch maxillary incisors score if 6 or more to denote esthetic handicap....................................................__________

Grand Total __________ C. Dentofacial Deviations

The following deviations are scored as handicapping when associated with malocclusion: Score 8 points for each deviation.

1. Facial and oral clefts

2. Lower lip palatal to maxillary incisor teeth

3. Occlusal interference

Possible Surgical Indication 4. Functional jaw limitations

Yes No 5. Facial asymmetry

6. Speech impairment

7. Total Score

TOTAL SALZMANN INDEX:


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Malocclusion Severity Assessment By J.A. Salzmann, DDS, F.A.P.H.A.

Summary of instructions Score: 2 points for each maxillary anterior tooth affected. 1 point for each mandibular incisor and all posterior teeth affected. 1. Missing teeth. Count the teeth; remaining roots of teeth are scored as a missing tooth. 2. Crowding. Score the points when there is not sufficient space to align a tooth without moving other

teeth in the same arch. 3. Rotation. Score the points when one or both proximal surfaces are seen in anterior teeth, or all or

part of the buccal or lingual surface in posterior teeth are turned to a proximal surface of an adjacent tooth. The space needed for tooth alignment is sufficient in rotated teeth for their proper alignment.

4. Spacing. Score teeth, not spacing. Score the points when: a. Open spacing. One or both interproximal tooth surfaces and adjacent papillae are visible in

an anterior tooth; both interproximal surfaces and papillae are visible in a posterior tooth. b. Closed spacing. Space is not sufficient to permit eruption of a tooth that is partially eruption.

5. Overjet. Score the points when the mandibular incisors occlude on or over the maxillary mucosa in back of the maxillary incisors, and the mandibular incisor crowns show labial axial inclination.

6. Overbite. Score the points when the maxillary incisors occlude on or opposite labial gingival mucosa of the mandibular incisor teeth.

7. Cross-bite. Score the points when the maxillary incisors occlude lingual to mandibular incisors, and the posterior teeth occlude entirely out of occlusal contact.

8. Open-bite. Score the points when the teeth occlude above the opposing incisal edges and above the opposing occlusal surfaces of posterior teeth.

9. Mesiodistal deviations. Relate mandibular to opposing maxillary teeth by full cusp for molars; buccal cusps of premolars and canines occlude mesial or distal to accepted normal interdental area of maxillary premolars.

Instruction for using the “Handicapping Malocclusion Assessment Record” Introduction This assessment record (not an examination) is intended to disclose whether a handicapping malocclusion is present and to assess its severity according to the criteria and weights (point values) assigned to them. The weights are based on tested clinical orthodontic values from the standpoint of the effect of the malocclusion on dental health, function, and esthetics. The assessment is not directed to ascertain the presence of occlusal deviations ordinarily included in epidemiological surveys of malocclusion. Etiology, diagnosis, planning, complexity of treatment, and prognosis are not factors in this assessment. Assessments can be made from casts or directly in the mouth. An additional assessment record form is provided for direct mouth assessment of mandibular function, facial asymmetry, and lower lip position.


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A. Intra-Arch Deviations

The casts are placed, teeth upward, in direct view. When the assessment is made directly in the mouth, a mouth mirror is used. The number of teeth affected is entered as indicated in the “Handicapping Malocclusion Assessment Record.” The scoring can be entered later.

1. Anterior segment: A value of 2 points is scored for each tooth affected in the maxilla

and 1 point in the mandible.

a. Missing teeth are assessed by actual count. A tooth with only the roots remaining is scored as missing.

b. Crowded refers to tooth irregularities that interrupt the continuity of the dental arch when

the space is insufficient for alignment without moving other teeth in the arch. Crowded teeth may or may not also be rotated. A tooth scored as crowded is not scored also as rotated.

c. Rotated refers to tooth irregularities that interrupt the continuity of the dental arch but

there is sufficient space for alignment. A tooth scored as rotated is not scored also as crowded or spaced.

d. Spacing

(1) Open spacing refers to tooth separation that exposes to view the interdental papillac on the alveolar crest. Score the number of papillae visible (not teeth).

(2) Closed spacing refers to partial space closure that will not permit a tooth to complete

its eruption without moving other teeth in the same arch. Score the number of teeth affected.

2. Posterior segment: A value of 1 point is scored of each tooth affected.

a. Missing teeth are assessed by actual count. A tooth with only the roots remaining is scored as missing.

b. Crowded refers to tooth irregularities that interrupt the continuity of the dental arch when

the space is insufficient for alignment. Crowded teeth may or may not also be rotated. A tooth scored as crowded is not scored also as rotated.

c. Rotated refers to tooth irregularities that interrupt the continuity of the dental arch and all

or part of the lingual or buccal surface faces some part or all of the adjacent proximal tooth surfaces. There is sufficient space for alignment. A tooth scored as rotated is not scored also as crowded.

d. Spacing

(1) Open spacing refers to interproximal tooth separation that exposes to view the mesial and distal papillae of a tooth. Score the number of teeth affected (Not the spaces).

(2) Closed spacing refers to partial space closure that will not permit a tooth to erupt without moving other teeth in the same arch. Score the number of teeth affected.


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B. Interarch Deviations

When casts are assessed for interarch deviations, they first are approximated in terminal occlusion. Each side assessed is held in direct view. When the assessment is made in the mouth, terminal occlusion is obtained by bending the head backward as far as possible while the mouth is held wide open. The tongue is bent upward and backward on the palate and the teeth are quickly brought to terminal occlusion before the head is again brought downward. A mouth mirror is used to obtain a more direct view in the mouth.

1. Anterior segment: A value of 2 points is scored for each affected maxillary tooth

only.

a. Overjet refers to labial axial inclination of the maxillary incisors in relation to the mandibular incisor, permitting the latter to occlude on or over the palatal mucosa. If the maxillary incisors are not in labial axial inclination, the condition is scored as overbite only.

b. Overbite refers to the occlusion of the maxillary incisors on or over the labial gingival

mucosa of the mandibular incisors, while the mandibular incisors themselves occlude on or over the palatal mucosa in back of the maxillary incisors. When the maxillary incisors are in labial axial inclination, the deviation is scored also as overjet.

c. Cross-bite refers to maxillary incisors that occlude lingual to their opponents in the

opposing jaw, when the teeth are in terminal occlusion.

d. Open-bite refers to vertical interach dental separation between the upper and lower incisors when the posterior teeth are in terminal occlusion. Open-bite is scored in addition to overjet if the maxillary incisor teeth are above the incisal edges of the mandibular incisors when the posterior teeth are in terminal occlusion edge-to-edge occlusion in not assessed as open-bite.

2. Posterior segment: A value of 1 point is scored for each affected tooth.

a. Cross-bite refers to teeth in the buccal segment that are positioned lingually or buccally out of entire occlusal contact with the teeth in the opposing jaw when the dental arches are in terminal occlusion.

b. Open-bite refers to the vertical interdental separation between the upper and lower

segments when the anterior teeth are in terminal occlusion. Cusp-to-cusp occlusion is not assessed as open-bite.

c. Anteroposterior deviation refers to the occlusion forward or rearward of the accepted

normal of the mandibular canine, first and second premolars, and first molar in relation to the opposing maxillary teeth. The deviation is scored when it extends a full cusp or more in the molar and the premolars and canine occlude in the interproximal area mesial or distal to the accepted normal position.

C. Dentofacial Deviations

The following deviations are scored as handicapping when associated with a malocclusion: Score eight (8) points for each deviation.

1. Facial and oral clefts. 2. Lower lip positioned completely palatal to the maxillary incisor teeth. 3. Occlusal interference that cannot be corrected by a less intrusive therapy. 4. Functional jaw limitations. 5. Facial asymmetry to the extent that surgical intervention is indicated. 6. Speech impairment documented by a licensed or certified therapist whose cause is related to

the improper placement of the dental units.


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060101-IL H-1

ATTACHMENT G

Patient Recall System Requirements Recall System Requirements

Each participating office should maintain and document a formal system for patient recall. The system can utilize either written or phone contact. Any system should encompass routine patient check-ups, cleaning appointments, follow-up treatment appointments, and missed appointments for any Participant that has sought dental treatment.

Office Compliance Verification Procedures

In conjunction with its office claim audits described in section 5, Doral will measure compliance with the requirement to maintain a patient recall system.

Participating Dentists are expected to meet minimum standards with regard to appointment availability. Emergent situations (those involving pain, infection, swelling and/or traumatic injury) need to be appointed within 24 hours. Urgent care should be available within 72 hours. Initial and Recall routine treatment should be scheduled within 30 days of initial contact with the dentist’s office. Follow-up appointments should be scheduled within 45 days of the present treatment date. Providers should see a Participant within 40 minutes of arriving at the office for a scheduled appointment.

ATTACHMENT H


060101-IL H-2

The Patient Record A. Organization

1. The record must have areas for documentation of the following information:

a. Registration data including a complete health history. b. Medical alert predominantly displayed. c. Initial examination data. d. Radiographs. e. Periodontal and Occlusal status. f. Treatment plan/Alternative treatment plan. g. Progress notes to include diagnosis, preventive services, treatment rendered, and

medical/dental consultations. h. Miscellaneous items (correspondence, referrals, and clinical laboratory reports).

2. The design of the record must provide the capability or periodic update, without the loss of

documentation of the previous status, of the following information:

a. Health history b. Medical alert c. Examination/Recall data d. Periodontal status e. Treatment plan

3. The design of the record must ensure that all permanent components of the record are attached

or secured within the record. 4. The design of the record must ensure that all components must be readily identified to the patient

(i.e., patient name, or identification number on each page).

5. The organization of the record system must require that individual records be assigned to each patient.

B. Content - The patient record should be organized in such a fashion to contain the following:

1. Adequate documentation of registration information, which requires entry of these items:

a. Patient’s first and last name b. Date of birth c. Sex d. Address e. Telephone number

2. Name and telephone number of the person to contact in case of emergency. 3. An adequate health history that documents:

a. Current medical treatment b. Significant past illnesses c. Current medications


060101-IL H-3

d. Drug allergies e. Hematologic disorders. Cardiovascular disorders f. Respiratory disorders g. Endocrine disorders h. Communicable diseases i. Neurologic disorders j. Signature and date by patient k. Signature and date by reviewing dentist l. History of alcohol and tobacco usage including smokeless tobacco

4. An adequate update of health history at subsequent recall examinations, which documents a

minimum of:

a. Significant changes in health status b. Current medical treatment c. Current medications d. Dental problems/concerns e. Signature and date by reviewing dentist

5. A conspicuously placed medical alert that documents highly significant terms from health history.

These items may include:

a. Health problems, which contraindicate certain types of dental treatment b. Health problems that require precautions or pre-medication prior to dental treatment c. Current medications that may contraindicate the use of certain types of drugs or

dental treatment d. Drug sensitivities e. Infectious diseases that may endanger personnel or other patients

6. Adequate documentation of the initial clinical examination, which is dated and describes:

a. Blood pressure (Recommended) b. Head/neck examination c. Soft tissue examination d. Periodontal assessment e. Occlusal classification f. Dentition charting

7. Adequate documentation of the patient’s status at subsequent Periodic/Recall examinations,

which is dated and describes changes/new findings in these items:

a. Blood pressure (Recommended) b. Head/neck examination c. Soft tissue examination d. Periodontal assessment e. Dentition charting

8. Radiographs, which are:

a. Identified by patient name b. Dated c. Designated by patient’s left and right side d. Mounted (if intraoral films)

9. An indication of the patient’s clinical problems/diagnosis.


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10. Adequate documentation of the treatment plan (including any alternate treatment options) that

specifically describes all the services planned for the patient by entry of these items:

a. Procedure b. Localization (area of mouth, tooth number, surface)

11. Adequate documentation of the periodontal status, if necessary, which is dated and describes:

a. Periodontal pocket depth b. Furcation involvement c. Mobility d. Recession e. Adequacy of attached gingiva f. Missing teeth

12. Adequate documentation of the patient’s oral hygiene status and preventive efforts, which

documents:

a. Gingival status b. Amount of plaque c. Amount of calculus d. Education provided to the patient e. Patient receptiveness/compliance f. Recall interval g. Date

13. Adequate documentation of medical and dental consultations within and outside the practice,

which describes:

a. Provider to whom consultation is directed b. Information/services requested c. Consultant’s response

14. Adequate documentation of treatment rendered which verifies the claims submitted, identifying:

a. Date of service/procedure b. Description of service, procedure and observation c. Type and dosage of anesthetics and medications given or prescribed d. Localization of procedure/observation (tooth #, quadrant etc.) e. Signature of the Provider who rendered the service

15. Adequate documentation of the specialty care performed by another dentist that includes:

a. Patient examination b. Treatment plan c. Treatment status


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C. Compliance

1. The patient record has one explicitly defined format that is currently in use. 2. There is consistent use of each component of the patient record by all staff. 3. The components of the record that are required for complete documentation of each patient’s

status and care are present. 4. Entries in the records are legible. 5. Entries of symbols and abbreviations in the records are uniform, easily interpreted and are

commonly understood in the practice.


060101-IL I-1

ATTACHMENT I

Office Claim Audit

A. Purpose

Doral utilizes a proprietary paperless process to collect procedure information and determine the value of services rendered by each participating office. Additionally, Doral has substituted specific dental treatment protocols and related documentation requirements for prior-authorization procedures utilized by many traditional dental PPOs. The resulting streamlined process greatly reduces the administrative burden of Doral’s participating dentists by recognizing the fundamental difference between monitoring necessary and appropriate dental services and traditional medical utilization management. Despite the obvious benefits of the streamlined process, Doral’s paperless system could potentially be abused by fraudulent claim entry. In order to assure its dental panel Participants that such efforts will be identified and appropriately dealt with, Doral has designed a fraud detection program that provides a 98% probability of detecting fraudulent claim submission.

B. Random Chart Audits

On a periodic basis, Doral takes a sample of claims submitted by selected office locations. Doral provides this listing of Participants and dates of service to the office location. For each Participant and date of service, the office must supply complete dental records to support the services billed. These records will be reviewed to ensure compliance with the Participant record protocols, as well as to detect possible billing irregularities. Each office may either make copies of the records requested or arrange for a Doral representative to review the original records at the office location itself. Doral claim audits will be scheduled on a random basis. Doral shall make every effort to schedule these reviews at times that are convenient for the office and will make every effort to complete the review in as short a duration as is practical.


060101-IL I-2


060101-IL J-1

ATTACHMENT J

Radiology Guidelines

Note: Please refer to benefit tables for benefit limitations. Doral utilizes the guidelines published by the Department of Health and Human Services, Center for Devices and Radiological Health. These guidelines were developed in conjunction with the Food and Drug Administration. A. Radiographic Examination of the New Patient

Child – Primary Dentition

The Panel recommends Posterior Bitewing radiographs for a new patient, with a primary dentition and closed proximal contacts.

Child – Transitional Dentition

The Panel recommends an individualized Periapical/Occlusal examination with Posterior Bitewings OR a Panoramic X-ray and Posterior Bitewings, for a new patient with a transitional dentition.

Adolescent – Permanent Dentition Prior to the eruption of the third molars

The Panel recommends and individualized radiographic examination consisting of selected periapicals with posterior Bitewings for a new adolescent patient.

Adult – Dentulous

The Panel recommends and individualized radiographic examination consisting of selected periapicals with posterior bitewings for a new dentulous adult patient.

Adult – Edentulous

The Panel recommends a Full-Mouth Intraoral Radiographic Survey or a Panoramic X-ray for the new edentulous adult patient.

B. Radiographic Examination of the Recall Patient

1. Patients with clinical caries or other high – risk factors for caries

a. Child – Primary and Transitional Dentition

The Panel recommends that Posterior Bitewings be performed at a 6-12 month interval for those children with clinical caries or who are at increased risk for the development of caries in either the primary or transitional dentition.

b. Adolescent

The Panel recommends that Posterior Bitewings be performed at a 6-12 month interval for adolescents with clinical caries or who are at increased risk for the development of caries.

c. Adult – Dentulous

The Panel recommends that Posterior Bitewings be performed at a 6-12 month interval for adults with clinical caries or who are at increased risk for the development of caries.


060101-IL J-2

d. Adult – Edentulous

The Panel found that an examination for occult disease in this group can not be justified on the basis of prevalence, morbidity, mortality, radiation dose and cost. Therefore, the Panel recommends that no x-rays be performed for edentulous recall patients without clinical signs or symptoms.

2. Patients with no clinical caries and no other high risk factors for caries

a. Child – Primary Dentition

The Panel recommends that Posterior bitewings be performed at an interval of 12-24 months for children with a primary dentition with closed posterior contacts who show no clinical caries and are not at increased risk for the development of caries.

b. Adolescent

The Panel recommends that Posterior Bitewings be performed at intervals of 12-24 months for patients with a transitional dentition who show no clinical caries and are not at an increased risk for the development of caries.

c. Adult – Dentulous

The Panel recommends that Posterior Bitewings be performed at intervals of 24-36 months for dentulous adult patients who show no clinical caries and are not at an increased risk for the development of caries.

3. Patients with periodontal disease, or a history of periodontal treatment for Child – Primary and Transitional Dentition, Adolescent and Dentulous Adult.

The Panel recommends an individualized radiographic survey consisted of selected Periapicals and/or Bitewing radiographs of areas with clinical evidence or a history of periodontal disease, (except nonspecific gingivitis).

4. Growth and Development Assessment

Child – Primary Dentition

The panel recommends that prior to the eruption of the first permanent tooth, no radiographs be performed to assess growth and development at recall visits in the absence of clinical signs or symptoms.

Child – Transitional Dentition

The Panel recommended and individualized Periapical/Occlusal series OR a Panoramic X-ray to assess growth and development at the first recall visit for a child after the eruption of the first permanent tooth.

Adolescent

The Panel recommended that for the adolescent (age 16-19 years of age) recall patient, a single set of Periapicals of the wisdom teeth or a panoramic radiograph.

Adult

The Panel recommends that no radiographs be performed on adults to assess growth and development in the absence of clinical signs or symptoms.


060101-IL L-1

ATTACHMENT K

Note: The above form is intended to be a sample. Doral is not mandating the use of this form. Please refer to State statutes for specific State requirements and guidelines.


060101-IL L-2


060101-IL M-1

ATTACHMENT L

RECALL EXAMINATION

PATIENT’S NAME _________________________________________________________________________________ CHANGES IN HEALTH STATUS/MEDICAL HISTORY _____________________________________________________ ________________________________________________________________________________________________ OK OK LYMPH NODES TMJ PHARYNX TONGUE TONSILS VESTIBULES SOFT PALATE BUCCAL MUCOSA HARD PALATE GINGIVA FLOOR OF MOUTH PROSTHESIS LIPS PERIO EXAM SKIN ORAL HYGIENE RADIOGRAPHS B/P RDH/DDS

CLINICAL FINDINGS/COMMENTS

R WORK NECESSARY L TOOTH 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 SERVICE TOOTH 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 SERVICE

COMMENTS: _____________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________

RECALL EXAMINATION

PATIENT’S NAME _________________________________________________________________________________ CHANGES IN HEALTH STATUS/MEDICAL HISTORY _____________________________________________________ ________________________________________________________________________________________________ OK OK LYMPH NODES TMJ PHARYNX TONGUE TONSILS VESTIBULES SOFT PALATE BUCCAL MUCOSA HARD PALATE GINGIVA FLOOR OF MOUTH PROSTHESIS LIPS PERIO EXAM SKIN ORAL HYGIENE RADIOGRAPHS B/P RDH/DDS

CLINICAL FINDINGS/COMMENTS

R WORK NECESSARY L TOOTH 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 SERVICE TOOTH 32 31 30 29 28 27 26 25 24 23 22 21 20 19 18 17 SERVICE

COMMENTS: _____________________________________________________________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________

NOTE: The above form is intended to be a sample. Doral is not mandating the use of this form. Please refer to State statutes for specific State requirements and guidelines.


060101-IL M-2


060101-IL N-1

ATTACHMENT M

Authorization for Dental Treatment

I hereby authorize Dr. ___________________________ and his/her associates to provide dental services, prescribe, dispense and/or administer any drugs, medicaments, antibiotics, and local anesthetics that he/she or his/her associates deem, in their professional judgement, necessary or appropriate in my care. I am informed and fully understand that there are inherent risks involved in the administration of any drug, medicament, antibiotic, or local anesthetic. I am informed and fully understand that there are inherent risks involved in any dental treatment and extractions (tooth removal). The most common risks can include, but are not limited to:

Bleeding, swelling, bruising, discomfort, stiff jaws, infection, aspiration, paresthesia, nerve disturbance or damage either temporary or permanent, adverse drug response, allergic reaction, cardiac arrest.

I realize that it is mandatory that I follow any instructions given by the dentist and/or his/her associates and take any medication as directed. Alternative treatment options, including no treatment, have been discussed and understood. No guarantees have been made as to the results of treatment. A full explanation of all complications is available to me upon request from the dentist. Procedure(s): _________________________________________________________________ Tooth Number(s): ______________________________________________________________ Date: _____________________________________ Dentist: __________________________________ Patient Name: _____________________________ Legal Guardian/ Patient Signature: ___________________________ Witness: __________________________________ Note: The above form is intended to be a sample. Doral is not mandating the use of this form. Please refer to State statutes for specific State requirements and guidelines.


060101-IL N-2


060101-IL O-1

ATTACHMENT N

MEDICAL AND DENTAL HISTORY

Patient Name: _________________________________ Date of Birth: ___________________

Address: _____________________________________________________________________

Why are you here today? ________________________________________________________ Are you having pain or discomfort at this time? Yes No If yes, what type and where? ___________________________________________________ Have you been under the care of a medical doctor during the past two years? Yes No

Medical Doctor’s Name: __________________________________________________ Address: ______________________________________________________________ Telephone: ____________________________________________________________

Have you taken any medication or drugs during the past two years? Yes No Are you now taking any medication, drugs, or pills? Yes No

If yes, please list medications: ____________________________________________

Are you aware of being allergic to or have you ever reacted badly to any medication or substance? Yes No

If yes, please list: ______________________________________________________

When you walk up stairs or take a walk, do you ever have to stop because of pain in your chest, shortness or breath, or because you are very tired? Yes No Do your ankles swell during the day? Yes No Do you use more than two pillows to sleep? Yes No Have you lost or gained more than 10 pounds in the past year? Yes No Do you ever wake up from sleep and feel short of breath? Yes No Are you on a special diet? Yes No Has your medical doctor ever said you have cancer or a tumor? Yes No

If yes, where? _________________________________________________________

Do you use tobacco products (smoke or chew tobacco)? Yes No

If yes, how often and how much? __________________________________________

Do you drink alcoholic beverages (beer, wine, whiskey, etc.)? Yes No


060101

Do you have or have you had any disease, or condition not listed? Yes No

If yes, please list: _______________________________________________________

Indicate which of the following your have had, or have at present. Circle “Yes” or “No” for each item. Heart Disease or Attack

Yes No Artificial Joints (Hip, Knee, etc.)

Yes No Hepatitis A (infectious)

Yes No

Heart Failure Yes No Stroke Yes No Hepatitis B (serum) Yes No Angina Pectoris Yes No Kidney Trouble Yes No Hepatitis C Yes No Congenital Heart Disease

Yes No High Blood Pressure

Yes No Arteriosclerosis (hardening of arteries)

Yes No

Kidney Trouble Yes No Venereal Disease Yes No Ulcers Yes No Diabetes Yes No Heart Murmur Yes No AIDS Yes No HIV Positive Yes No Glaucoma Yes No Blood Transfusion Yes No High Blood Pressure

Yes No Cortisone Medication

Yes No Cold sores/Fever blisters/ Herpes

Yes No

Mitral Valve Prolapse

Yes No Cosmetic Surgery

Yes No Artificial Heart Valve Yes No

Emphysema Yes No Anemia Yes No Heart Pacemaker Yes No Chronic Cough Yes No Heart Surgery Yes No Sickle Cell Disease Yes No Tuberculosis Yes No Bruise Easily Yes No Asthma Yes No Liver Disease Yes No Rheumatic fever Yes No Yellow Jaundice Yes No Arthritis Yes No Hay Fever Yes No Rheumatism Yes No Allergies or Hives

Yes No Epilepsy or Seizures

Yes No Fainting or Dizzy Spells

Yes No

Sinus Trouble Yes No Nervousness Yes No Chemotherapy Yes No Pain in Jaw Joints

Yes No Radiation Therapy

Yes No Drug Addiction Yes No

Hay Fever Yes No Thyroid Problems Yes No Psychiatric Treatment Yes No For Women Only: Are you pregnant? Yes No

If yes, what month? ____________________________________________________ Are you nursing? Yes No Are you taking birth control pills? Yes No I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions truthfully. Patient Signature: _____________________________ Date: _________________________ Dentist’s Signature: ____________________________ Date: _________________________ Review Date Changes in

Health Status Patient’s signature

Dentist’s signature
Note: The above form is intended to be a sample. Doral is not mandating the use of thisform. Please refer to State statutes for specific State requirements and guidelines.
-IL O-2


ATTACHMENT O

Doral Dental Services of Illinois, LLC Healthcare and Family Services

Medical Assistance Fee Schedule for Children Participants Rates Effective January 1, 2006

Procedure

Code Procedure

Maximum Allowance

D0120 Periodic Oral Exam – Ages 0 thru 18 28.00D0120 Periodic Oral Exam –Ages 19 thru 20 16.20D0140 Limited Oral Examination – Problem Focused 16.20D0150 Comprehensive Oral Examination 21.05D0210 Intraoral-Complete Series (including bitewings) 30.10D0220 Intraoral – periapical – first film 5.60D0230 Intraoral periapical – 1 additional film 3.80D0270 Bitewings Single Film 5.60D0272 Bitewings-Two Films 9.40D0274 Bitewings-Four Films 16.90D0277 Vertical Bitewings – 7-8 Films 16.90D0330 Panoramic Film 22.60D1120 Prophylaxis - Child – Ages 0 thru 18 41.00D1120 Prophylaxis - Child – Ages 19 thru 20 25.40D1203 Topical Application of Fluoride (excluding prophy) – Ages 0 thru 18 26.00D1203 Topical Application of Fluoride (excluding prophy) – Ages 19 thru 20 14.85D1351 Sealant – Per Tooth 36.00D1510 Space Maintainer - Fixed Unilateral 70.60D1515 Space Maintainer - Fixed Bilateral 103.50D1525 Space Maintainer - Removable Bilateral 74.70D1550 Space Maintainer – Recement 10.70D2140 Amalgam-1-Surface, Primary or Permanent 30.85D2150 Amalgam-2-Surfaces, Primary or Permanent 48.15D2160 Amalgam-3-Surfaces, Primary or Permanent 58.05D2161 Amalgam-4+-Surface, Primary or Permanent 58.05D2330 Resin-Based Composite - 1-Surface, Anterior 34.60D2331 Resin-Based Composite - 2-Surfaces, Anterior 51.90D2332 Resin-Based Composite - 3-Surfaces, Anterior 61.80D2335 Resin-Based Composite – 4+ surfaces, or involving Incisal Edge, Anterior 61.80D2391 Resin-Based Composite – 1-surface, Primary or Permanent 30.85D2392 Resin-Based Composite – 2-surfaces, Primary or Permanent 48.15D2393 Resin-Based Composite – 3-surfaces, Primary or Permanent 58.05D2394 Resin-Based Composite – 4+surfaces, Primary or Permanent 58.05D2740 Crown – porc/ceramic 235.20D2750 Crown – porc/metal high noble 235.20D2751 Crown-Porcelain/Base Metal 235.20D2752 Crown – porcelain/metal noble 235.20D2790 Crown – full metal high noble 145.85D2791 Crown - Full Cast Base Metal 145.85D2792 Crown – full metal noble 145.85D2910 Recement Inlays 11.30

060101-IL P-1


Procedure Code

Procedure

Maximum Allowance

D2915 Recement cast or prefabricated post and core 23.50D2920 Recement Crown 23.50D2930 Prefabricated Stainless Steel Crown (SSC) Primary Tooth 73.40D2931 Prefabricated Stainless Steel Crown (SSC) Permanent Tooth 73.40D2932 Prefabricated Resin Crown 56.45D2940 Sedative fillings 11.30D2951 Pin Retention-Per Tooth 9.40D2954 Prefabricated Post and Core 32.90D3220 Therapeutic Pulpotomy 52.70D3310 Anterior Root Canal (Excluding Final Restoration) 136.40D3320 Bicuspid Root Canal (Excluding Final Restoration) 155.25D3330 Molar Root Canal (Excluding Final Restoration) 202.30D3351 Apexification/Recalcification Initial Visit 28.20D3352 Apexification/Recalcification Interim Visit 14.10D3353 Apexification/Recalcification Final Visit 14.10D3410 Apicoectomy/Periadicular Surgery –– Per Tooth, First Root 112.90D4210 Gingivectomy or Gingivoplasty –– 4+ Teeth, Per Quadrant 131.70D4211 Gingivectomy or Gingivoplasty –– 1 to 3 Teeth, Per Quadrant 65.85D4240 Gingival Flap Procedure, w/ Root Planing – 4+ Teeth, Per Quadrant 229.60D4241 Gingival Flap Procedure, w/ Root Planing – 1 to 3 Teeth, Per Quadrant 114.80D4260 Osseous Surgery – 4+ Teeth, Per Quadrant 277.60D4261 Osseous Surgery – 1 to 3 Teeth, Per Quadrant 138.80D4263 Bone Replacement Graft –– First Site in Quadrant 141.15D4264 Bone Replacement Graft, Each Additional Site in Quadrant 70.60D4270 Pedicle Soft Tissue Graft 141.15D4271 Free Soft Tissue Graft 141.15D4273 Subepithelial Connective Tissue Graft Procedure 141.15D4274 Distal or Proximal Wedge 70.60D4320 Provisional Splinting, Intracoronal 188.20D4321 Provisional Splinting, Extracoronal 56.50D4341 Periodontal Scaling and Root Planing – 4+ Teeth, Per Quadrant 80.00D4342 Periodontal Scaling and Root Planing – 1 to 3 Teeth, Per Quadrant 40.00D4910 Periodontal Maintenance Procedure 47.05D5110 Complete Denture - Maxillary 376.35D5120 Complete Denture - Mandibular 376.35D5130 Immediate Denture – Maxillary 376.35D5140 Immediate Denture – Mandibular 376.35D5211 Maxillary Partial Denture –– Resin Base 357.55D5212 Mandibular Partial Denture –– Resin Base 357.55D5213 Maxillary Partial Denture –– Cast Metal Framework 366.95D5214 Mandibular Partial Denture –– Cast Metal Framework 366.95D5510 Repair Complete Denture Base 61.15D5520 Replace Missing or Broken Teeth, Complete Denture 38.10D5610 Repair Partial Denture Base 51.75D5620 Repair Cast Framework 79.05

060101-IL P-2


Procedure Code

Procedure

Maximum Allowance

D5630 Repair or Replace Broken Clasp 71.50D5640 Replace Broken Teeth, Each Additional Tooth 37.65D5650 Add Tooth to Existing Partial 42.35D5730 Reline Complete Maxillary Denture, Chairside 70.60D5731 Reline Complete Mandibular Denture, Chairside 70.60D5740 Reline Maxillary Partial Denture, Chairside 70.60D5741 Reline Mandibular Partial Denture, Chairside 70.60D5750 Reline Complete Maxillary Denture, Laboratory 117.60D5751 Reline Complete Mandibular Denture, Laboratory 117.60D5760 Reline Maxillary Partial Denture, Laboratory 117.60D5761 Reline Mandibular Partial Denture, Laboratory 117.60D5911 Facial Moulage-sectional By ReportD5912 Facial Moulage-complete By ReportD5913 Nasal Prosthesis By ReportD5914 Auricular Prosthesis By ReportD5915 Orbital Prosthesis By ReportD5916 Ocular Prosthesis By ReportD5919 Facial Prosthesis By ReportD5922 Nasal Septal Prosthesis By ReportD5923 Ocular Prosthesis, interim By ReportD5924 Cranial Prosthesis By ReportD5925 Facial Augmentation implant Prosthesis By ReportD5926 Nasal Prosthesis, replacement By ReportD5927 Auricular Prosthesis, replacement By ReportD5928 Orbital Prosthesis, replacement By ReportD5929 Facial Prosthesis, replacement By ReportD5931 Obturator Prosthesis, surgical By ReportD5932 Obturator Prosthesis, definitive By ReportD5933 Obturator Prosthesis, modification By ReportD5934 Mandibular Resection Prosthesis with guide flanges By ReportD5935 Mandibular Resection Prosthesis without guide flanges By ReportD5936 Obturator Prosthesis, interim By ReportD5937 Trismus Appliance By ReportD5951 Feeding Aid By ReportD5952 Speech Aid Prosthesis, pediatric By ReportD5953 Speech Aid Prosthesis, adult By ReportD5954 Palatal Augmentation, Prosthesis By ReportD5955 Palatal Lift Prosthesis, definitive By ReportD5958 Palatal Lift Prosthesis, Interim By ReportD5959 Palatal Lift Prosthesis, modification By ReportD5960 Speech Aid Prosthesis, modification By ReportD5982 Surgical Stent By ReportD5983 Radiation Carrier By ReportD5984 Radiation Shield By ReportD5985 Radiation Cone Locator By ReportD5986 Fluoride Gel Carrier By ReportD5987 Commissure Splint By Report

060101-IL P-3


Procedure Code

Procedure

Maximum Allowance

D5988 Surgical Splint By ReportD5999 Unspecified Maxillofacial Prosthesis By ReportD6210 Pontic crown – metal high noble 178.80D6211 Pontic crown – metal base 178.80D6212 Pontic crown – metal noble 178.80D6240 Pontic crown – porc/metal high noble 178.80D6241 Pontic crown - porc/base Metal 178.80D6242 Pontic crown – porc metal noble 178.80D6251 Pontic-Resin/Base Metal 103.50D6721 Crown-Resin/Predominately Base Metal 136.40D6750 Crown – porc/metal high noble 159.95D6751 Crown-Porcelain/Predominately Base Metal 159.95D6752 Crown – porc/metal noble 159.95D6790 Crown – full metal high noble 159.95D6791 Crown - full metal base 159.95D6792 Crown - full metal noble 159.95D6930 Recement Fixed Partial Denture 32.90D6972 Prefabricated Post and Core in Addition to Fixed Partial Denture Retainer 26.35D7140 Extraction – Erupted Tooth or Exposed Root 39.12D7210 Surgical Removal of Erupted Tooth 57.40D7220 Removal of Impacted Tooth –– Soft Tissue 66.80D7230 Removal for Impacted Tooth –– Partially Bony 86.60D7240 Removal of Impacted Tooth –– Completely Bony 100.70D7250 Surgical Removal of Residual Roots 51.75D7280 Surgical access of unerupted tooth 50.80D7283 Placement of device to facilitate eruption of impacted tooth 45.00D7310 Alveoloplasty in Conjunction with Extractions –– per quadrant 64.00D7311 Alveoloplasty w/ extraction – 1-3 teeth/spaces per quad 64.00D7320 Alveoloplasty Not in Conjunction With Extractions –– per quadrant 64.00D7321 Alveoloplasty w/o extractions – 1- 3 teeth/spaces per quad 64.00D7450 Removal of Odontogenic Cyst or Tumor up to 1.25cm 94.30D7451 Removal of Odontogenic Cyst orTumor over 1.25cm 199.60D7460 Removal of Non-Odontogenic Cyst or Tumor up to 1.25cm 94.30D7461 Removal of Non-Odontogenic Cyst or Tumor over 1.25cm 199.60 D7510 Incision and Drainage Abscess 36.70D7511 Incision & drainage – intraoral - complicated 36.70D7610 Maxilla Open Reduction, Teeth Immobilized 657.95D7620 Maxilla Closed Reduction, Teeth Immobilized 471.50D7630 Mandible-Open Reduction, Teeth Immobilized 824.65D7640 Mandible-Closed Reduction, Teeth Immobilized 706.95D7710 Maxilla-Open Reduction 1059.35D7720 Maxilla-Closed Reduction 706.35D7730 Mandible-Open Reduction 1059.35D7740 Mandible-Closed Reduction 706.20D7810 Open Reduction of Dislocation 438.60D7820 Closed Reduction of Dislocation 177.65D7960 Frenulectomy-Separate Procedure (frenectomy or frenotomy) 77.15D7963 Frenuloplasty 77.15D8080 Initial Orthodontic Appliance Placement 588.05D8660 Initial Examination, Records, Radiographs & Facial Photographs 75.30

060101-IL P-4


Procedure Code

Procedure

Maximum Allowance

D8670 Monthly Adjustments 89.90D8999 Initial Orthodontic Evaluation/Study Models 47.05D9110 Palliative (emergency) Treatment of Dental Pain-Minor Procedures 14.10D9220 General Anesthesia – Require Dental Sedation Permit B to bill 59.30D9230 Analgesia, anxiolysis, inhalation of nitrous oxide 12.20D9241 Intravenous Sedation – Require Dental Sedation Permit A to bill 59.30D9248 Non-intravenous conscious sedation – Require Dental Sedation Permit A to bill 35.00D9310 Consultation 17.10D9610 Therapeutic Drug Injection By ReportD9630 Other Drugs and Medicaments 23.50D9999 Unspecified Procedure, By Report By Report

060101-IL P-5


060101-IL P-6


ATTACHMENT P

Doral Dental Services of Illinois, LLC Healthcare and Family Services

Medical Assistance Fee Schedule for Adult Participants Rates Effective January 1, 2006

Procedure

Code Procedure

Maximum Allowance

D0140 Limited Oral Examination - Problem Focused 16.20D0150 Comprehensive Oral Examination 21.05D0210 Intraoral-Complete Series (including bitewings) 30.10D0220 Intraoral - periapical ––first film 5.60D0230 Intraoral periapical – 1 additional film 3.80D0270 Bitewings Single Film 5.60D0272 Bitewings-Two Films 9.40D0274 Bitewings-Four Films 16.90D0277 Vertical Bitewings – 7-8 Films 16.90D0330 Panoramic Film 22.60D2140 Amalgam-1-Surface, Primary or Permanent 30.85D2150 Amalgam-2-Surfaces, Primary or Permanent 48.15D2160 Amalgam-3-Surfaces, Primary or Permanent 58.05D2161 Amalgam-4+-Surface, Primary or Permanent 58.05D2330 Resin-Based Composite - 1-Surface, Anterior 34.60D2331 Resin-Based Composite - 2-Surfaces, Anterior 51.90D2332 Resin-Based Composite - 3-Surfaces, Anterior 61.80D2335 Resin-Based Composite – 4+ surfaces, or involving Incisal Edge, Anterior 61.80D2391 Resin-Based Composite – 1-surface, Primary or Permanent 30.85D2392 Resin-Based Composite – 2-surfaces, Primary or Permanent 48.15D2393 Resin-Based Composite – 3-surfaces, Primary or Permanent 58.05D2394 Resin-Based Composite – 4+surfaces, Primary or Permanent 58.05D2740 Crown – porc/ceramic 235.20D2750 Crown – porc/metal high noble 235.20D2751 Crown-Porcelain/Base Metal 235.20D2752 Crown-Porcelain/metal noble 235.20D2790 Crown – full metal high noble 145.85D2791 Crown - Full Cast Base Metal 145.85D2792 Crown – full metal noble 145.85D2910 Recement Inlays 11.30D2915 Recement cast of prefabricated post and core 23.50D2920 Recement Crown 23.50D2931 Prefabricated Stainless Steel Crown (SSC) Permanent Tooth 73.40D2932 Prefabricated Resin Crown 56.45D2940 Sedative fillings 11.30D2951 Pin Retention-Per Tooth 9.40D2954 Prefabricated Post and Core 32.90D3310 Anterior Root Canal (Excluding Final Restoration) 136.40D5110 Complete Denture - Maxillary 376.35D5120 Complete Denture - Mandibular 376.35D5130 Immediate Denture – Maxillary 376.35D5140 Immediate Denture – Mandibular 376.35D5510 Repair Complete Denture Base 61.15

060101-IL Q-1


Procedure Code

Procedure

Maximum Allowance

D5520 Replace Missing or Broken Teeth, Complete Denture 38.10D5610 Repair Partial Denture Base 51.75D5620 Repair Cast Framework 79.05D5630 Repair or Replace Broken Clasp 71.50D5640 Replace Broken Teeth, Each Additional Tooth 37.65D5650 Add Tooth to Existing Partial 42.35D5730 Reline Complete Maxillary Denture, Chairside 70.60D5731 Reline Complete Mandibular Denture, Chairside 70.60D5740 Reline Maxillary Partial Denture, Chairside 70.60D5741 Reline Mandibular Partial Denture, Chairside 70.60D5750 Reline Complete Maxillary Denture, Laboratory 117.60D5751 Reline Complete Mandibular Denture, Laboratory 117.60D5760 Reline Maxillary Partial Denture, Laboratory 117.60D5761 Reline Mandibular Partial Denture, Laboratory 117.60D5911 Facial Moulage-sectional By ReportD5912 Facial Moulage-complete By ReportD5913 Nasal Prosthesis By ReportD5914 Auricular Prosthesis By ReportD5915 Orbital Prosthesis By ReportD5916 Ocular Prosthesis By ReportD5919 Facial Prosthesis By ReportD5922 Nasal Septal Prosthesis By ReportD5923 Ocular Prosthesis, interim By ReportD5924 Cranial Prosthesis By ReportD5925 Facial Augmentation implant Prosthesis By ReportD5926 Nasal Prosthesis, replacement By ReportD5927 Auricular Prosthesis, replacement By ReportD5928 Orbital Prosthesis, replacement By ReportD5929 Facial Prosthesis, replacement By ReportD5931 Obturator Prosthesis, surgical By ReportD5932 Obturator Prosthesis, definitive By ReportD5933 Obturator Prosthesis, modification By ReportD5934 Mandibular Resection Prosthesis with guide flanges By ReportD5935 Mandibular Resection Prosthesis without guide flanges By ReportD5936 Obturator Prosthesis, interim By ReportD5937 Trismus Appliance By ReportD5951 Feeding Aid By ReportD5953 Speech Aid Prosthesis, adult By ReportD5954 Palatal Augmentation, Prosthesis By ReportD5955 Palatal Lift Prosthesis, definitive By ReportD5958 Palatal Lift Prosthesis, Interim By ReportD5959 Palatal Lift Prosthesis, modification By ReportD5960 Speech Aid Prosthesis, modification By ReportD5982 Surgical Stent By ReportD5983 Radiation Carrier By ReportD5984 Radiation Shield By ReportD5985 Radiation Cone Locator By ReportD5986 Fluoride Gel Carrier By ReportD5987 Commissure Splint By ReportD5988 Surgical Splint By Report

060101-IL Q-2


Procedure Code

Procedure

Maximum Allowance

D5999 Unspecified Maxillofacial Prosthesis By ReportD6930 Recement Fixed Partial Denture 32.90D7140 Extraction – Erupted Tooth or Exposed Root 39.12D7210 Surgical Removal of Erupted Tooth 57.40D7220 Removal of Impacted Tooth –– Soft Tissue 66.80D7230 Removal for Impacted Tooth –– Partially Bony 86.60D7240 Removal of Impacted Tooth –– Completely Bony 100.70D7250 Surgical Removal of Residual Roots 51.75D7450 Removal of Odontogenic Cyst or Tumor up to 1.25cm 94.30D7451 Removal of Odontogenic Cyst orTumor over 1.25cm 199.60D7460 Removal of Non-Odontogenic Cyst or Tumor up to 1.25cm 94.30D7461 Removal of Non-Odontogenic Cyst or Tumor over 1.25cm 199.60 D7510 Incision and Drainage Abscess 36.70D7511 Incision and dranage – intraoral – complicated 36.70D7610 Maxilla Open Reduction, Teeth Immobilized 657.95D7620 Maxilla Closed Reduction, Teeth Immobilized 471.50D7630 Mandible-Open Reduction, Teeth Immobilized 824.65D7640 Mandible-Closed Reduction, Teeth Immobilized 706.95D7710 Maxilla-Open Reduction 1059.35D7720 Maxilla-Closed Reduction 706.35D7730 Mandible-Open Reduction 1059.35D7740 Mandible-Closed Reduction 706.20D7810 Open Reduction of Dislocation 438.60D7820 Closed Reduction of Dislocation 177.65D9110 Palliative (emergency) Treatment of Dental Pain-Minor Procedures 14.10D9220 General Anesthesia – Require Dental Sedation Permit B to bill 59.30D9230 Analgesia, anxiolysis, inhalation of nitrous oxide 12.20D9241 Intravenous Sedation – Require Dental Sedation Permit A to bill 59.30D9248 Non-Intravenous conscious sedation – Require Dental Sedation Permit A to 35.00D9310 Consultation 17.10D9610 Therapeutic Drug Injection By ReportD9630 Other Drugs and Medicaments 23.50D9999 Unspecified Procedure, By Report By Report

060101-IL Q-3


060101-IL Q-4


060101-IL Q-1

Attachment Q: Benefits Covered - CHILDREN UNDER AGE 21

Diagnostic services include the oral examinations and selected radiographs needed to assess oral health, diagnose oral pathology and develop an adequate treatment plan for the Participant’s oral health.

Reimbursement for radiographs includes exposure of the radiograph, developing, mounting and radiographic interpretation. Reimbursement for multiple radiographs of the same tooth or area may be denied if Doral determines the number to be redundant, excessive or not in keeping with the federal policies relating to radiation exposure. Doral utilizes the guidelines published by the Department of Health and Human Services, Center for Devices and Radiological Health. These guidelines were developed in conjunction with the Food and Drug Administration and are described in Attachment J of this manual.

If the total allowed amount for radiographs performed on a participant exceeds the allowed amount for procedure code D0210 (Complete Series), the submitted radiograph codes will be consolidated and paid as a Complete Series (D0210). The maximum reimbursement for a single date of service for radiographs shall be limited to the fee for a complete service.

An initial examination is typically used when evaluating a patient comprehensively. It is a thorough evaluation and recording of the extraoral and intraoral hard and soft tissues. It may require interpretation of information acquired through additional diagnostic procedures. Additional diagnostic procedures should be reported separately.

This would include the evaluation and recording of the patient’s dental and medical history and a general health assessment. It may typically include the evaluation and recording of dental caries, missing or unerupted teeth, restorations, occlusal relationships, periodontal conditions (including periodontal charting), hard and soft tissue anomalies, oral cancer screening, etc.

A periodic examination is performed on a patient of record to determine any changes in the patient’s dental and medical health status since a previous comprehensive or periodic evaluation. This may require interpretation of information acquired through additional diagnostic procedures. Report additional diagnostic procedures separately.

A complete Early Periodic Screening, Diagnosis and Treatment (EPSDT) examination is used when evaluating a child comprehensively. It is a thorough evaluation and a recording of the extraoral and intraoral hard and soft tissues. This would include the evaluation and recording of the patient’s dental and medical history and a general health assessment. It may typically include the evaluation and recording of dental caries, missing or unerupted teeth, restorations, occlusal relationships, periodontal conditions (including periodontal charting), hard and soft tissue anomalies, oral cancer screening, etc.

PLACE OF SERVICE MUST BE INDICATED ON ALL CLAIMS.

OUT-OF-OFFICE SERVICES: Providers who render preventive exams in an out-of-office setting must check the "Other" box on the ADA form or, if filing electronically, put code 03 for school or 99 for other, as appropriate. Providers who render comprehensive services in an out-of-office setting must check the “Provider’s Office” or “ECF” box on the ADA form, or, if filing electronically, put code 15 for mobile unit, 32 for an extended care facility or 99 for other, as appropriate.

Code DescriptionAge

Limitation Teeth Covered Benefit Limitations Documentation Required

Diagnostic

Authorization Required

Illinois Medical Assistance - Under 21Page 1 of 51Doral Dental Services of Illinois, LLC 20051201


Code DescriptionAge


Diagnostic


D0120 periodic oral evaluation No0 - 20 One per 12 months. Participants are also eligible for one periodic oral evaluation (D0120) performed in an out of office setting per 12 months.

Place of service.

D0140 limited oral evaluation - problem focused No0 - 20 Limited emergency exam will only be covered when performed in conjunction with treatment to address an emergency situation. An emergency will be defined as treatment medically necessary to treat pain, infection, swelling, uncontrolled bleeding or traumatic injury. Not allowed with D9110.

Description of the emergency and description of services provided with claim.

D0150 comprehensive oral evaluation - new or established patient

No0 - 20 Once per lifetime. One comprehensive exam per patient per dentist or dental group per lifetime.

D0210 intraoral - complete series (including bitewings)

No0 - 20 One per 36 months.

D0220 intraoral - periapical first film No0 - 20 Maximum of one (1) per day per patient per dentist or dental group.



Code DescriptionAge


Diagnostic


D0230 intraoral - periapical each additional film No0 - 20 Maximum reimbursement for a single date of service for radiographs limited to fee for Complete Series (D0210).

D0270 bitewing - single film No0 - 20 Maximum reimbursement for a single date of service for radiographs limited to fee for Complete Series (D0210).

D0272 bitewings - two films No0 - 20 Maximum reimbursement for a single date of service for radiographs limited to fee for Complete Series (D0210).

D0274 bitewings - four films No0 - 20 Maximum reimbursement for a single date of service for radiographs limited to fee for Complete Series (D0210).

D0277 vertical bitewings - 7 to 8 films No0 - 20 Maximum reimbursement for a single date of service for radiographs limited to fee for Complete Series (D0210).



Code DescriptionAge


Diagnostic


D0330 panoramic film No3 - 20 One per 36 months. Maximum reimbursement for a single date of service for radiographs limited to fee for Complete Series (D0210).



Preventive services include routine and EPSDT prophylaxis (including scaling and polishing), topical fluoride treatments, dental sealants, and space maintenance therapy for Participants age 0 through 20. The goal of providing routine and periodic preventive dental services is to maintain oral health and prevent more extensive dental procedures.

Routine prophylaxis is covered for Participants age 0 through 20, once every 6 months. Prophylaxis includes necessary scaling and polishing.

The topical application of fluoride treatment is allowed once every 12 months for Participants age 0 through 20.

Sealants are covered for Participants age 5 through 17. Sealants should be applied to the occlusal surfaces of all erupted and appropriate first and second permanent molars. Priority should be given to applying sealants for all 7 and 12 year olds. Sealants will not be covered when they are placed over restorations.

Space maintainers are a covered service for Participants age 2 through 20 when determined by a Doral Consultant to be indicated due to the premature loss of a posterior primary tooth. Space maintainers will not be covered if premolar eruption is imminent.

A lower lingual holding arch placed when there is not premature loss of a primary molar is considered a transitional orthodontic appliance and not a covered benefit.


OUT-OF-OFFICE SERVICES: Providers who render preventive services in an out-of-office setting must check the "Other" box on the ADA form or, if filing electronically, put code 03 for school or 99 for other, as appropriate. Providers who render comprehensive services in an out-of-office setting must check the “Provider’s Office” or “ECF” box on the ADA form, or, if filing electronically, put code 15 for mobile unit, 32 for an extended care facility or 99 for other, as appropriate.

Dental providers who are performing preventive out-of-office services must have the ability to provide all four preventive treatment services. Services cannot be limited to only exams, cleaning and fluoride treatment. Each provider must provide any follow up sealants in addition to the exam, cleaning, and fluoride treatment when needed.

Code DescriptionAge


Preventive


D1120 prophylaxis - child No0 - 20 One per 6 months. Removal of plaque, calculus and stains from the tooth surfaces. Intended to control local irrational factors.

Place of serivce.



Code DescriptionAge


Preventive


D1203 topical application of fluoride (prophylaxis not included) - child

No0 - 20 One per 12 months. Prescription strength fluoride designed soley for use in the dental office, delivered to the dentition under the direct supervision of a dental professional.

Place of serivce.

D1351 sealant - per tooth Teeth 2, 3, 14, 15, 18, 19, 30, 31 No5 - 17 Once per lifetime. Occlusal surfaces only. Teeth must be caries free. Sealant will not be covered when placed over restorations.

D1510 space maintainer - fixed - unilateral Per quadrant - 10 (UR), 20 (UL), 30 (LL), 40 (LR)

Yes2 - 20 Covered when indicated due to premature loss of posterior primary teeth.

Pre-operative radiographs.

D1515 space maintainer - fixed - biilateral Upper Arch 01 (UA) or Lower Arch 02 (LA)



D1525 space maintainer - removable - biilateral Upper Arch 01 (UA) or Lower Arch 02 (LA)





Code DescriptionAge


Preventive


D1550 re-cementation space maintainer No2 - 20



Restorative services (amalgams and composites) are provided to remove decay and restore dental structures (teeth) to a reasonable condition. Payment is made for restorative services based on the number of surfaces restored, not on the number of restorations per surface, or per tooth, per day.

Bases, cements, liners, pulp caps, bonding agents and local anesthetic are included in the restorative service fees and are not reimbursed separately.

Restorations are expected to last a reasonable amount of time. Repeated unexplained failures will result in review by Peer Review and may necessitate removal of the dentist from the panel.

Code DescriptionAge


Restorative


D2140 amalgam - one surface, primary or permanent

Teeth 1 through 32, A through T No0 - 20

D2150 amalgam - two surfaces, primary or permanent


D2160 amalgam - three surfaces, primary or permanent


D2161 amalgam - four or more surfaces, primary or permanent




Code DescriptionAge


Restorative


D2330 resin-based composite - one surface, anterior

Teeth 6 - 11, 22 - 27, C - H, M - R No0 - 20

D2331 resin-based composite - two surfaces, anterior

Teeth 6 - 11, 22 - 27, C - H, M - R No0 - 20

D2332 resin-based composite - three surfaces, anterior

Teeth 6 - 11, 22 - 27, C - H, M - R No0 - 20

D2335 resin-based composite - four surfaces, anterior

Teeth 6 - 11, 22 - 27, C - H, M - R No0 - 20

D2391 resin-based composite - one surface, posterior

Teeth 1 - 5, 12 - 21, 28 - 32, A, B, I, J, K, L, S, T

No0 - 20



Code DescriptionAge


Restorative


D2392 resin-based composite - two surfaces posterior

Teeth 1 - 5, 12 - 21, 28 - 32, A, B, I, J, K, L, S, T

No0 - 20

D2393 resin-based composite - three surfaces, posterior

Teeth 1 - 5, 12 - 21, 28 - 32, A, B, I, J, K, L, S, T

No0 - 20

D2394 resin-based composite - four or more surfaces, posterior

Teeth 1 - 5, 12 - 21, 28 - 32, A, B, I, J, K, L, S, T

No0 - 20

D2740 crown - porcelain/ceramic substrate Teeth 4 - 13, 20 - 29 Yes0 - 20 One per 60 months. Pre-operative radiographs.

D2750 crown - porcelain fused to high noble metal Teeth 4 - 13, 20 - 29 Yes0 - 20 One per 60 months. Pre-operative radiographs.



Code DescriptionAge


Restorative


D2751 crown - porcelain fused to predominantly base metal

Teeth 4 - 13, 20 - 29 Yes0 - 20 One per 60 months. Pre-operative radiographs.

D2752 crown - porcelain fused to noble metal Teeth 4 - 13, 20 - 29 Yes0 - 20 One per 60 months. Pre-operative radiographs.

D2790 crown - full cast high noble metal Teeth 1 through 32 Yes0 - 20 One per 60 months. Pre-operative radiographs.

D2791 crown - full cast predominantly base metal Teeth 1 through 32 Yes0 - 20 One per 60 months. Pre-operative radiographs.

D2792 crown - full cast noble metal Teeth 1 through 32 Yes0 - 20 One per 60 months. Pre-operative radiographs.



Code DescriptionAge


Restorative


D2910 recement inlay, onlay, or partial coverage restoration

Teeth 1 through 32 No0 - 20

D2915 recement cast or prefabricated post and core


D2920 recement crown Teeth 1 through 32, A through T No0 - 20

D2930 prefabricated stainless steel crown - primary tooth

Teeth A through T Yes0 - 20 Authorization required for two (2) or more crowns. Pre-operative radiographs.

D2931 prefabricated stainless steel crown - permanent tooth

Teeth 1 through 32 Yes2 - 20 Authorization required for two (2) or more crowns. Not compensated with construction of permanent crown.




Code DescriptionAge


Restorative


D2932 prefabricated resin crown Teeth 6 - 11, 22 - 27, C - H, M - R Yes0 - 20 Authorization required for two (2) or more crowns. Pre-operative radiographs.

D2940 sedative filling Teeth 1 through 32, A through T No0 - 20

D2951 pin retention - per tooth, in addidtion to restoration


D2954 prefabricated post and core in addition to crown

Teeth 1 through 32 Yes0 - 20 Endodontic fill radiograph.



Endodontic services are provided to retain teeth through root canal therapy made necessary due to trauma or carious exposure.

The following guidelines must be followed when providing endodontic services:

Pulpotomies will only be covered on primary teeth with no evidence of internal resorption, furcation or periapical pathologic involvement.

The standard of acceptability employed for endodontic procedures requires that the canal(s) be completely filled apically and laterally. In cases where the root canal filling does not meet Doral’s treatment standards, Doral can require the procedure to be redone at no additional cost. Any reimbursement already made for an inadequate service may be recouped after the Doral Consultant reviews the circumstances.

Root canal therapy for permanent teeth includes diagnosis, extirpation of the pulp, shaping and enlarging the canals, temporary fillings, filling and obliteration of root canal(s), and progress radiographs. The fee does not include the final restoration.

Root canals and pulpotomies may not be covered in the following situations:

* Root resorption has started and exfoliation is imminent* Gross periapical or periodontal pathosis is demonstrated radiographically (caries to the furcation, or subcrestal deeming the tooth non-restorable)* The general oral condition does not justify root canal therapy due to the loss of arch integrity* Tooth does not demonstrate 50% bone support* Tooth demonstrates active untreated periodontal disease

Code DescriptionAge


Endodontics


D3220 therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction and application of medicament

Teeth A through T No0 - 20 Not reimbursable when performed in conjunction with a root canal - Primary Teeth Only.

D3310 root canal - anterior (excluding final restoration)

Teeth 6 - 11, 22 - 27 No2 - 20 Once per lifetime.



Code DescriptionAge


Endodontics


D3320 root canal - bicuspid (excluding final restoration)

Teeth 4, 5, 12, 13, 20, 21, 28, 29 No2 - 20 Once per lifetime.

D3330 root canal - molar (excluding final restoration)

Teeth 1 - 3, 14 - 19, 30 - 32 No2 - 20 Once per lifetime.

D3351 apexification/recalcification - initial visit (apical closure/clacific repair of perforations, root receptions, etc.)

Teeth 1 through 32 Yes2 - 20 Once per lifetime. Pre-operative radiograph.

D3352 apexification/recalcification - interim mediciation replacement (apical closure/clacific repair of perforations, root receptions, etc.)

Teeth 1 through 32 Yes2 - 20 Once per lifetime. Pre-operative radiograph with claim.

D3353 apexification/recalcification - final visit (includes completed root canal therapy - apical closure/clacific repair of perforations, root receptions, etc.)

Teeth 1 through 32 Yes2 - 20 Once per lifetime. Pre-operative radiograph and fill radiograph with claim.



Code DescriptionAge


Endodontics


D3410 apicoectomy/periradicular surgery - anterior Teeth 6 - 11, 22 - 27 Yes2 - 20 Not payable concurrently with root canal treatment of tooth.

Pre-operative radiograph.



Periodontal scaling and root planing, gingivectomy, and certain other procedures as required can be considered for coverage. The initial stages of therapy should include Oral Hygiene Instructions and treatment to remove deposits. Surgical intervention will not be considered until there is a sufficient amount of time for healing and re-evaluation.

Code DescriptionAge


Periodontics


D4210 gingivectomy/gingivoplasty - four or more contiguous teeth or bounded teeth spaces per quadrant

Per quadrant - 10 (UR), 20 (UL), 30 (LL), 40 (LR)

Yes0 - 20 Pre-operative radiographs and periodontal charting.

D4211 gingivectomy/gingivoplasty - one to three contiguous teeth or bounded teeth spaces per quadrant



D4240 gingival flap w/ root planing - four or more contiguous teeth or bounded teeth spaces per quadrant



D4241 gingival flap w/ root planing - one to three contiguous teeth or bounded teeth spaces per quadrant



D4260 osseous surgery - four or more contiguous teeth or bounded teeth spaces per quadrant





Code DescriptionAge


Periodontics


D4261 osseous surgery - one to three contiguous teeth or bounded teeth spaces per quadrant



D4263 bone replacement graft - first site in quadrant

Teeth 1 through 32 Yes0 - 20 Pre-operative radiographs and periodontal charting.

D4264 bone replacement graft - each additional site in quadrant


D4270 pedicle soft tissue graft procedure Teeth 1 through 32 Yes0 - 20 Pre-operative radiographs and periodontal charting.

D4271 free soft tissue graft procedure (including donor site surgery)




Code DescriptionAge


Periodontics


D4273 subepithelial connectivbe tissue graft procedures, per tooth


D4274 distal or proximal wedge procedure (when not performed in conjunction with surgical procedures)


D4320 provisional splinting - intracoronal Upper Arch 01 (UA) or Lower Arch 02 (LA)


D4321 provisional splinting - extracoronal Upper Arch 01 (UA) or Lower Arch 02 (LA)


D4341 periodontal scaling and root planing - four or more teeth per quadrant


Yes0 - 20 One per 24 months. One full mouth service is covered every 24 months.

Pre-operative radiographs and periodontal charting.



Code DescriptionAge


Periodontics


D4342 periodontal scaling and root planing - one to three teeth per quadrant


Yes0 - 20 One per 24 months. One full mouth service is covered every 24 months.


D4910 periodontal maintenance Yes0 - 20 Only covered after active therapy has been performed.




Provisions for removable prosthesis include initial placement when masticatory function is impaired or when existing prosthesis is at least five years old and unserviceable. All necessary restorative work must be completed before fabrication of a partial denture. Abutments for partial dentures must be free of active periodontal disease, and have at least 50% bone support.

Payment for dentures includes any necessary adjustments, repairs or relines necessary during the six - (6) month period following delivery of a new prosthesis. Relines are covered once every 24 months. The reimbursement for an incomplete denture service (non-delivery) will be limited to the out-of-pocket costs as documented by a copy of the lab bill. THE DATE OF PLACEMENT MUST BE USED AS THE DATE OF SERVICE WHEN SUBMITTING FOR PAYMENT OF DENTURES. Extractions and other procedures necessary prior to denture placement must be rendered and paid before dentures will be reimbursed. If immediate dentures, extractions must be rendered and billed with the same date of service as placement of the immediate dentures.

In situations where it is impractical to obtain pre-operative radiographs on a patient in a nursing home or long term care facility, a written narrative by the dentist stating that the patient is in a physical and mental state sufficient to function with full dentures is required for authorization.

Denture benefits for patients with the following medical conditions will not be considered for coverage:

* Patients on feeding tubes* Post CVA patients with decreased facial muscle tone* Patients in a coma* Patients with diminished mental capacities that could not function with dentures* Patients who do not desire dentures* Advanced terminal patients

Code DescriptionAge


Prosthodontics, removeable


D5110 complete denture - maxillary Yes0 - 20 One per 60 months. (D5110 or D5130). Pre-operative full mouth radiographs. Date of prior placement (if applicable).

D5120 complete denture - mandibular Yes0 - 20 One per 60 months. (D5120 or D5140). Pre-operative full mouth radiographs. Date of prior placement (if applicable).



Code DescriptionAge




D5130 immediate denture - maxillary Yes0 - 20 One per 60 months. (D5110 or D5130). Pre-operative full mouth radiographs.

D5140 immediate denture - mandibular Yes0 - 20 One per 60 months. (D5120 or D5140). Pre-operative full mouth radiographs.

D5211 maxillary partial denture - resin base (including any conventional clasps, rests and teeth)

Yes2 - 20 One per 60 months. (D5211 or D5213). Pre-operative full mouth radiographs. Date of prior placement (if applicable).

D5212 mandibular partial denture - resin base (including any conventional clasps, rests and teeth)


D5213 maxillary partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)




Code DescriptionAge




D5214 mandibular partial denture - cast metal framework with resin denture bases (including any conventional clasps, rests and teeth)


D5510 repair broken complete denture base Upper Arch 01 (UA) or Lower Arch 02 (LA)

No0 - 20

D5520 replace missing or broken teeth - complete denture (each tooth)


D5610 repair resin denture base Upper Arch 01 (UA) or Lower Arch 02 (LA)

No0 - 20

D5620 repair cast framework Upper Arch 01 (UA) or Lower Arch 02 (LA)

No0 - 20



Code DescriptionAge




D5630 repair or replace broken clasp No0 - 20

D5640 replace broken teeth - per tooth Teeth 1 through 32 No0 - 20

D5650 add tooth to existing partial denture Teeth 1 through 32 No0 - 20

D5730 reline complete maxillary denture (chairside)

Yes0 - 20 One per 24 months. Date of denture placement.

D5731 reline complete mandibular denture (chairside)




Code DescriptionAge




D5740 reline maxillary partial denture (chairside) Yes0 - 20 One per 24 months. Date of denture placement.

D5741 reline mandibular partial denture (chairside) Yes0 - 20 One per 24 months. Date of denture placement.

D5750 reline complete maxillary denture (laboratory)


D5751 reline complete mandibular denture (laboratory)


D5760 reline maxillary partial denture (laboratory) Yes0 - 20 One per 24 months. Date of denture placement.



Code DescriptionAge




D5761 reline mandibular partial denture (laboratory)




Code DescriptionAge


Maxillofacial Prosthetics


D5911 facial moulage (sectional) Yes0 - 20 Narrative of medical necessity.

D5912 facial moulage (complete) Yes0 - 20 Narrative of medical necessity.

D5913 nasal prosthesis Yes0 - 20 Narrative of medical necessity.

D5914 auricular prosthesis Yes0 - 20 Narrative of medical necessity.

D5915 orbital prosthesis Yes0 - 20 Narrative of medical necessity.



Code DescriptionAge




D5916 ocular prosthesis Yes0 - 20 Narrative of medical necessity.

D5919 facial prosthesis Yes0 - 20 Narrative of medical necessity.

D5922 nasal septal prosthesis Yes0 - 20 Narrative of medical necessity.

D5923 ocular prosthesis, interim Yes0 - 20 Narrative of medical necessity.

D5924 cranial prosthesis Yes0 - 20 Narrative of medical necessity.



Code DescriptionAge




D5925 facial augmentation implant prosthesis Yes0 - 20 Narrative of medical necessity.

D5926 nasal prosthesis, replacement Yes0 - 20 Narrative of medical necessity.

D5927 auricular prosthesis, replacement Yes0 - 20 Narrative of medical necessity.

D5928 orbital prosthesis, replacement Yes0 - 20 Narrative of medical necessity.

D5929 facial prosthesis, replacement Yes0 - 20 Narrative of medical necessity.



Code DescriptionAge




D5931 obturator prosthesis, surgical Yes0 - 20 Narrative of medical necessity.

D5932 obturator prosthesis, definitive Yes0 - 20 Narrative of medical necessity.

D5933 obturator prosthesis, modification Yes0 - 20 Narrative of medical necessity.

D5934 mandibular resection prosthesis with guide flange

Yes0 - 20 Narrative of medical necessity.

D5935 mandibular resection prosthesis without guide flange




Code DescriptionAge




D5936 obturator prosthesis, interim Yes0 - 20 Narrative of medical necessity.

D5937 trismus appliance (not for TMD treatment) Yes0 - 20 Not for TMD Treatment. Narrative of medical necessity.

D5951 feeding aid Yes0 - 20 Narrative of medical necessity.

D5952 speech aid prosthesis, pediatric Yes0 - 12 Narrative of medical necessity.

D5953 speech aid prosthesis, adult Yes13 - 20 Narrative of medical necessity.



Code DescriptionAge




D5954 palatal augmentation prosthesis Yes0 - 20 Narrative of medical necessity.

D5955 palatal lift prosthesis, definitive Yes0 - 20 Narrative of medical necessity.

D5958 palatal lift prosthesis, interim Yes0 - 20 Narrative of medical necessity.

D5959 palatal lift prosthesis, modification Yes0 - 20 Narrative of medical necessity.

D5960 speech aid prosthesis, modification Yes0 - 20 Narrative of medical necessity.



Code DescriptionAge




D5982 surgical stent Yes0 - 20 Narrative of medical necessity.

D5983 radiation carrier Yes0 - 20 Narrative of medical necessity.

D5984 radiation shield Yes0 - 20 Narrative of medical necessity.

D5985 radiation cone locator Yes0 - 20 Narrative of medical necessity.

D5986 fluoride gel carrier Yes0 - 20 Narrative of medical necessity.



Code DescriptionAge




D5987 commissure splint Yes0 - 20 Narrative of medical necessity.

D5988 surgical splint Yes0 - 20 Narrative of medical necessity.

D5999 unspecified maxillofacial prosthesis, by report




Fixed bridgework will only be considered for the replacement of the permanent anterior teeth.

Fixed Prosthetic Services are covered for Participants with prior authorization. Services will not be authorized until it is documented that all necessary restorative, endodontic, periodontic and oral surgery has been completed.

Fixed bridgework will not be allowed in conjunction with the placement of a partial denture in the same arch.

Fixed prosthesis will not be covered when they replace a removable appliance that is less than 5 years old.

Code DescriptionAge


Prosthodontics, fixed


D6210 pontic - cast high noble metal Teeth 6 - 11, 22 - 27 Yes2 - 20 One per 60 months. Pre-operative radiographs. Date of prior placement (if applicable).

D6211 pontic - predominantly base metal Teeth 6 - 11, 22 - 27 Yes2 - 20 One per 60 months. Pre-operative radiographs. Date of prior placement (if applicable).

D6212 pontic - cast noble metal Teeth 6 - 11, 22 - 27 Yes2 - 20 One per 60 months. Pre-operative radiographs. Date of prior placement (if applicable).

D6240 pontic - porcelain fused to high noble metal Teeth 6 - 11, 22 - 27 Yes2 - 20 One per 60 months. Pre-operative radiographs. Date of prior placement (if applicable).



Code DescriptionAge




D6241 pontic - porcelain fused to predominantly base metal

Teeth 6 - 11, 22 - 27 Yes2 - 20 One per 60 months. Pre-operative radiographs. Date of prior placement (if applicable).

D6242 pontic - porcelain fused to noble metal Teeth 6 - 11, 22 - 27 Yes2 - 20 One per 60 months. Pre-operative radiographs. Date of prior placement (if applicable).

D6251 pontic - resin with predominantly base metal


D6721 crown - resin with predominantly base metal Teeth 5 - 12, 20 - 29 Yes2 - 20 One per 60 months. Pre-operative radiographs. Date of prior placement (if applicable).

D6750 crown - porcelain fused to high noble metal Teeth 5 - 12, 20 - 29 Yes2 - 20 One per 60 months. Pre-operative radiographs. Date of prior placement (if applicable).



Code DescriptionAge






D6752 crown - porcelain fused to noble metal Teeth 5 - 12, 20 - 29 Yes2 - 20 One per 60 months.

D6790 crown - full cast high noble metal Teeth 5 - 12, 20 - 29 Yes2 - 20 One per 60 months. Pre-operative radiographs. Date of prior placement (if applicable).

D6791 crown - full cast predominantly base metal Teeth 5 - 12, 20 - 29 Yes2 - 20 One per 60 months. Pre-operative radiographs. Date of prior placement (if applicable).

D6792 crown - full cast noble metal Teeth 5 - 12, 20 - 29 Yes2 - 20 One per 60 months. Pre-operative radiographs. Date of prior placement (if applicable).



Code DescriptionAge




D6930 recement fixed partial denture No0 - 20

D6972 prefabricated post and core in addition to fixed partial denture retainer

Teeth 5 - 12, 20 - 29 Yes2 - 20 Endodontic fill radiograph.



Prophylactic removal of multiple asymptomatic teeth, or teeth free from pathology is not a covered benefit.

Extraction of deciduous teeth that radiographically appear to be near imminent exfoliation is not a covered benefit.

Reimbursement includes local anesthesia and post-operative care.

Claims for all oral surgical procedures except simple, non-surgical extractions or for procedure code D7210 must include a pre-operative radiograph to be considered for reimbursement.

Simple and surgical extractions are covered. Local anesthesia and routine post-operative care are included in the fees and will not be reimbursed separately.

“Erupted surgical extractions” are defined as extractions requiring elevation of a mucoperiosteal flap and removal of bone, and/or section of the tooth and closure.

Tuberosity reductions are not payable in conjunction with extractions or alveolectomy in the same quadrant.

For oral surgery performed as part of emergency care, the requirement for prior authorization is waived. Service will still be subject to retrospective review. Emergency care is defined as treatment of pain, infection, swelling, uncontrolled bleeding, or traumatic injury.

PROVIDERS BILLING ANESTHESIA SERVICES WITH ORAL SURGERY SERVICES MUST HAVE THE APPROPRIATE PERMITS IN ORDER TO BE REIMBURSED FOR SEDATION. SEE ANESTHESIA CODES FOR FURTHER DETAIL (D9220 - D9248).

Code DescriptionAge


Oral Surgery


D7140 extraction, erupted tooth or exposed root (elevation and/or forceps removal)

Teeth 1 through 32, 51 through 82 (SN), A through T, AS through TS (SN)

No0 - 20

D7210 surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth


No0 - 20 Prophylatic removal of asymptomatic tooth or tooth free from pathology is not a covered benefit.




Code DescriptionAge


Oral Surgery


D7220 removal of impacted tooth - soft tissue Teeth 1 through 32, 51 through 82 (SN)

Yes3 - 20 For Ages: 16 - 20; Teeth 1 - 32, 51 - 82 only. Prophylatic removal of asymptomatic tooth or tooth free from pathology is not a covered benefit

For Ages: 3 - 15; Teeth 51 - 82 only. Prophylatic removal of asymptomatic tooth or tooth free from pathology is not a covered benefit.


D7230 removal of impacted tooth - partially bone Teeth 1 through 32, 51 through 82 (SN)




D7240 removal of impacted tooth - completely bony

Teeth 1 through 32, 51 through 82 (SN)




D7250 surgical removal of residual roots (cutting procedure)


Yes2 - 20 Prophylatic removal of asymptomatic tooth or tooth free from pathology is not a covered benefit.


D7280 surgical access of unerupted tooth Teeth 1 through 32 Yes2 - 20 To expose crown of an impacted tooth not intended to be extracted.




Code DescriptionAge


Oral Surgery


D7283 placement of device to facilitate eruption of impacted tooth

Teeth 1 through 32 Yes2 - 20 Once per lifetime. ALLOWED ONLY ON APPROVED ORTHODONTIC CASES PER LIFETIME.

Pre-operative radiographs. For ortho cases only.

D7310 alveoloplasty in conjunction with extractions - per quadrant


Yes2 - 20 Once per lifetime. Either D7310 or D7311 per quad.


D7311 alveoloplasty in conjunction with extractions - one to three teeth or tooth spaces, per quadrant




D7320 alveoloplasty not in conjunction with extractions - per quadrant



Diagnostic models.

D7321 alveoloplasty not in conjunction with extractions - one to three teeth or tooth spaces, per quadrant



Diagnostic models.



Code DescriptionAge


Oral Surgery


D7450 removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm

Yes0 - 20 Copy of pathology report with claim.

D7451 removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm


D7460 removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm


D7461 removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cm


D7510 incision and drainage of abscess - intraoral soft tissue

Yes0 - 20 Either D7510 or D7511 on date of service. Pre-operative radiographs and narrative with claim.



Code DescriptionAge


Oral Surgery


D7511 incision and drainage of abscess - intraoral soft tissue - complicated (includes drainage of multiple fascial spaces)

Yes0 - 20 Includes drainage of multiple fascial spaces. Either D7510 or D7511 on date of service.

Pre-operative radiographs and narrative with claim.

D7610 maxilla - open reduction (teeth immobilized, if present)

Yes0 - 20 Pre-operative radiographs and accident narrative details with claim.

D7620 maxilla - closed reduction (teeth immobilized, if present)


D7630 mandible - open reduction (teeth immobilized, if present)


D7640 mandible - closed reduction (teeth immobilized, if present)




Code DescriptionAge


Oral Surgery


D7710 maxilla - open reduction Yes0 - 20 Pre-operative radiographs and accident narrative details with claim.

D7720 maxilla - closed reduction Yes0 - 20 Pre-operative radiographs and accident narrative details with claim.

D7730 mandible - open reduction Yes0 - 20 Pre-operative radiographs and accident narrative details with claim.

D7740 mandible - closed reduction Yes0 - 20 Pre-operative radiographs and accident narrative details with claim.

D7810 open reduction of dislocation Yes0 - 20 Narrative of medical necessity with claim.



Code DescriptionAge


Oral Surgery


D7820 closed reduction of dislocation Yes0 - 20 Narrative of medical necessity with claim.

D7960 frenulectomy - (frenectomy or frenotomy) - separate procedure

Yes2 - 20 Once per lifetime. One per arch per lifetime. Either D7960 or D7963.

Narrative of medical necessity. Study model or photo.

D7963 frenuloplasty Yes2 - 20 Once per lifetime. One per arch per lifetime. Either D7960 or D7963.

Narrative of medical necessity. Study model or photo.



Participants between the ages of 2 and 20 may qualify for orthodontic care under the program. PARTICIPANTS MUST HAVE A SEVERE, DYSFUNCTIONAL, HANDICAPPING MALOCCLUSION AS DETERMINED BY A SCORE OF 42 POINTS OR GREATER ON THE MODIFIED SALZMANN INDEX, OR OBJECTIVE DOCUMENTATION THAT THE MALOCCLUSION IS AN IMPAIRMENT OF, OR A HAZARD TO THE ABILITY TO EAT, CHEW, SPEAK, OR BREATHE. If it is determined that the case will not qualify for comprehensive orthodontic treatment, the initial examination (consultation) can be billed using procedure code D8999.

Since a case must be dysfunctional to be accepted for treatment, Participants whose molars and bicuspids are in good occlusion seldom qualify. INTERCEPTIVE ORTHODONTICS IS NOT A COVERED BENEFIT. Crowding alone is usually not dysfunctional in spite of the aesthetic considerations. THE PARTICIPANT MUST HAVE LOST ALL PRIMARY TEETH AND HAVE PERMANENT TEETH ERUPTING OR IN OCCLUSION TO BE CONSIDERED.

For cleft palate cases, please contact the Division of Specialized Care for Children (DSCC) at 1.800.322.3722.

All orthodontic services require prior authorization by a Doral Dental Consultant. Requests for prior authorization must include:

* Orthodontic examination and records* Appropriate radiographs and facial photographs* Study models properly trimmed and identified* Detailed treatment plan with diagnosis and prognosis

The charge for the initial exam, radiographs and study models should be submitted under procedure code D8660.

The date of service for orthodontic services is defined as the date when the bands, brackets, or appliances are placed in the Participant’s mouth. It is important to verify the Participant’s eligibility, as the Participant must be eligible on this date of service.

Payment for orthodontics includes all appliances, retainers and all follow-up visits. Orthodontic appliance benefit limited to once per lifetime.

To initiate payment on an approved comprehensive orthodontic case, the dental office must submit a claim form indicating the date the appliances were placed (banding date). IN ORDER TO RECEIVE REIMBURSEMENT FOR MONTHLY ADJUSTMENTS, PROVIDER MUST BILL FOR EACH DATE OF SERVICE TREATMENT WAS RENDERED. If a Participant fails to keep an appointment for two consecutive months, the dental office must notify Doral.

Continuation of orthodontic care will be handled as follows:

1. For cases that were started prior to the date the Participant was enrolled in the Medical Assistance program, Doral will attempt to secure the original pre-treatment records for review by a Doral Dental Consultant. The Modified Salzmann Index will be performed and the original records reviewed using the criteria for all new cases. If the original records pass the test of medical necessity, a continuation of benefits based on a proration of the remaining treatment will be authorized.

2. For cases that were started under the Medical Assistance Program, a Participant will be allowed to transfer treatment only under extreme situations. Usually this will be limited to when a Participant moves out of the immediate service area. In this instance, the dentist who will complete the treatment must submit a claim form indicating the treatment status of the case, his/her intention to continue care and a charge for the remaining treatment. Doral will review the request on a case by case basis and issue a determination of benefits.



Code DescriptionAge


Orthodontics


D8080 comprehensive orthodontic treatment of the adolescent dentition

Yes2 - 20 Once per lifetime. Study models (or OrthoCad equivalent) and radiographs.

D8660 pre-orthodontic treatment visit Yes2 - 20 Study models (or OrthoCad equivalent) and radiographs.

D8670 periodic orthodontic treatment visit (as part of contract)

Yes2 - 20 Maximum of one visit per month and 24 visits per lifetime.

D8999 unspecified orthodontic procedure, by report

Yes2 - 20 Once per lifetime. Only covered if case fails to reach 42 points on the Modified Salzman Index.



Adjunctive general services include general anesthesia, intravenous sedation, nitrous oxide analgesia, consultations and various drugs and medicaments, and emergency services provided for relief of dental pain.

Procedure code D9110 – palliative treatment is to be used to bill for minor palliative procedures when the only other procedure code billed for is a diagnostic radiograph. If any other services (filling, endodontics, oral surgery etc.) are billed for on the same day, the palliative treatment code will be denied.

Sedation and general anesthesia will only be a covered service for participating dentists that hold the applicable permits required by the Illinois Dental Practice Act.

Requests for sedation and general anesthesia will be reviewed on a case-by-case basis. A case will be covered for Participants with physical or mental health problems of such severity that treatment can not be reasonably attempted without the use of sedation or general anesthesia. Sedation or general anesthesia may be allowed when a surgical procedure is being rendered. Claims for sedation and general anesthesia must include a narrative of medical necessity. Acceptable conditions include:

* Toxicity to local anesthesia supported by documentation;* Severe mental retardation;* Severe physical disability;* Uncontrolled management problem;* Extensive or complicated surgical procedures;* Failure of local anesthesia;* Documented medical complications; and* Acute infection that would preclude the efficacy of local anesthesia.

For cases requiring sedation or general anesthesia, Providers must document the following in the Participant's chart for appropriate psychosomatic disorders: diagnosis, description of past evidence of situational anxiety or uncontrolledbehaviors, and in the case of referral due to uncontrolled behavior, the name of the referring dentist or provider group. Apprehension alone is not typically considered medically necessary. Doral or HFS may elect to perform chart audits on these services. Services not documented as required may be denied for payment. The procedures will only be reimbursed for once per day regardless of the length of time it takes to complete the procedure.

General anesthesia, intravenous sedation, conscious sedation and nitrous oxide are only covered in conjunction with a covered dental procedure. Payment for any one of these services precludes payment for the remaining procedure codes. Payment for general anesthesia, conscious sedation or intravenous sedation includes any other drugs administered on the same day.

Reimbursement for local anesthesia is included in the fee for the procedures.

Procedure code D9230 – nitrous oxide, is a covered service for Participants who are mentally or physically challenged, or otherwise present with special management needs. Special consideration is granted to individuals under the age of six that require extensive dental treatment and/or exhibit rampant caries where patient management is a concern.

Only claims for nitrous oxide with documented medical necessity will be considered for payment. Medical necessity for the use of nitrous oxide would be broadly defined as some condition specific to the particular treatment situation that would preclude the performance of necessary dental treatment, with the use of a local anesthetic alone.

Some examples of conditions that would establish medical necessity for nitrous oxide are:

* Apprehensive child under the age of six when any treatment is rendered



* Apprehensive children between 6 and 10 years of age when restorative or surgery is performed* Apprehensive children between the ages of 10 and 18 years when surgical services are performed

All other situations for nitrous oxide will be reviewed for coverage on a case-by-case basis.

Procedure code D9310 – consultation, will only be reimbursed to a dentist other than the one providing definitive treatment. A consultation includes an examination and evaluation of the patient, and a written report from the consultant to the treating dentist. When billing for a consultation, a copy of the written report must be attached. When the consulting dentist also performs services reimbursement to that dentist will be limited to the actual services performed. There will not be a separate reimbursement for a consultation.

Procedure code D9999 is to be utilized to submit a request for reimbursement for a dental service not otherwise described herein. Request should include a description of the service, medical necessity, a proposed fee and any pertinent radiographs.

IN ACCORDANCE WITH THE ILLINOIS DENTAL PRACTICE ACT, PROCEDURE CODES D9241 AND D9248 REQUIRE AN ANESTHESIA PERMIT A OR ANESTHESIA PERMIT B IN ORDER TO PERFORM SERVICE.

PROCEDURE CODE D9220 REQUIRES AN ANESTHESIA PERMIT B IN ORDER TO PERFORM SERVICE.

Code DescriptionAge


Adjunctive General


D9110 palliative (emergency) treatment of dental pain - minor procedure

No0 - 20 Not covered wth D0140 on same date of service.

D9220 deep sedation/general anesthesia - first 30 minutes

Yes0 - 20 Narrative of medical necessity. All inclusive fee - Not limited to first 30 minutes.

D9230 analgesia, anxiolysis, inhalation of nitrous oxide




Code DescriptionAge


Adjunctive General


D9241 intravenous conscious sedation/analgesia - first 30 minutes

Yes0 - 20 Narrative of medical necessity. All inclusive fee - Not limited to first 30 minutes.

D9248 non-intravenous conscious sedation/analgesia


D9310 consultation (diagnostic service provided by dentist or physician other than practitioner providing treatment)

No0 - 20 Narrative of medical necessity shall be maintained in patient records.

D9610 therapeutic drug injection, by report Yes0 - 20 Narrative of medical necessity. Name of drug and amount administered.

D9630 other drugs and/or medications, by report Yes0 - 20 Narrative of medical necessity. Name of drug and amount administered.



Code DescriptionAge


Adjunctive General


D9999 unspecified adjunctive procedure, by report Yes0 - 20 Description of service and narrative of medical necessity.


Attachment R: Benefits Covered - ADULTS - AGE 21 AND OVER

Diagnostic services include the oral examinations and selected radiographs needed to assess the oral health, diagnose oral pathology and develop an adequate treatment plan for the Participant’s oral health. Periodic exams are not a covered benefit for Participants age 21 and over.

Reimbursement for radiographs includes exposure of the radiograph, developing, mounting and radiographic interpretation. Reimbursement for multiple radiographs of the same tooth or area may be denied if Doral determines the number to be redundant, excessive or not in keeping with the federal policies relating to radiation exposure. Doral utilizes the guidelines published by the Department of Health and Human Services, Center for Devices and Radiological Health. These guidelines were developed in conjunction with the Food and Drug Administration and are described in Attachment J of this manual.

If the total allowed amount for radiographs performed on a participant exceeds the allowed amount for procedure code D0210 (Complete Series), the submitted radiograph codes will be consolidated and paid as a Complete Series (D0210). The maximum reimbursement for a single date of service for radiographs shall be limited to the fee for a complete service.

An initial examination is typically used when evaluating a patient comprehensively. It is a thorough evaluation and recording of the extraoral and intraoral hard and soft tissues. It may require interpretation of information acquired through additional diagnostic procedures. Additional diagnostic procedures should be reported separately.


Code DescriptionAge


Diagnostic


D0140 limited oral evaluation - problem focused No21 and older Limited emergency exam will only be covered when performed in conjunction with treatment to address an emergency situation. An emergency will be defined as treatment medically necessary to treat pain, infection, swelling, uncontrolled bleeding or traumatic injury. Not allowed with D9110.

Description of the emergency and description of services provided with claim.

D0150 comprehensive oral evaluation - new or established patient

No21 and older Once per lifetime. One comprehensive exam per patient per dentist or dental group per lifetime.

Illinois Medical Assistance - 21 and OverPage 1 of 33Doral Dental Services of Illinois, LLC 20051206


Code DescriptionAge


Diagnostic


D0210 intraoral - complete series (including bitewings)

No21 and older One per 36 months.

D0220 intraoral - periapical first film No21 and older Maximum of one (1) per day per patient per dentist or dental group.

D0230 intraoral - periapical each additional film No21 and older Maximum reimbursement for a single date of service for radiographs limited to fee for Complete Series (D0210).

D0270 bitewing - single film No21 and older Maximum reimbursement for a single date of service for radiographs limited to fee for Complete Series (D0210).

D0272 bitewings - two films No21 and older Maximum reimbursement for a single date of service for radiographs limited to fee for Complete Series (D0210).



Code DescriptionAge


Diagnostic


D0274 bitewings - four films No21 and older Maximum reimbursement for a single date of service for radiographs limited to fee for Complete Series (D0210).

D0277 vertical bitewings - 7 to 8 films No21 and older Maximum reimbursement for a single date of service for radiographs limited to fee for Complete Series (D0210).

D0330 panoramic film No21 and older One per 36 months. Maximum reimbursement for a single date of service for radiographs limited to fee for Complete Series (D0210).



Restorative services (amalgams and composites) are provided to remove decay and restore dental structures (teeth) to a reasonable condition. Payment is made for restorative services based on the number of surfaces restored, not on the number of restorations per surface, or per tooth, per day.

Bases, cements, liners, pulp caps, bonding agents and local anesthetic are included in the restorative service fees and are not reimbursed separately.

Restorations are expected to last a reasonable amount of time. Repeated unexplained failures will result in review by Peer Review and may necessitate removal of the dentist from the panel.

Code DescriptionAge


Restorative


D2140 amalgam - one surface, primary or permanent

Teeth 1 through 32, A through T No21 and older

D2150 amalgam - two surfaces, primary or permanent


D2160 amalgam - three surfaces, primary or permanent


D2161 amalgam - four or more surfaces, primary or permanent




Code DescriptionAge


Restorative


D2330 resin-based composite - one surface, anterior

Teeth 6 - 11, 22 - 27, C - H, M - R No21 and older

D2331 resin-based composite - two surfaces, anterior


D2332 resin-based composite - three surfaces, anterior


D2335 resin-based composite - four surfaces, anterior


D2391 resin-based composite - one surface, posterior

Teeth 1 - 5, 12 - 21, 28 - 32, A, B, I, J, K, L, S, T

No21 and older



Code DescriptionAge


Restorative


D2392 resin-based composite - two surfaces posterior

Teeth 1 - 5, 12 - 21, 28 - 32, A, B, I, J, K, L, S, T

No21 and older

D2393 resin-based composite - three surfaces, posterior

Teeth 1 - 5, 12 - 21, 28 - 32, A, B, I, J, K, L, S, T

No21 and older

D2394 resin-based composite - four or more surfaces, posterior

Teeth 1 - 5, 12 - 21, 28 - 32, A, B, I, J, K, L, S, T

No21 and older

D2740 crown - porcelain/ceramic substrate Teeth 4 - 13, 20 - 29 Yes21 and older One per 60 months. Pre-operative radiographs.

D2750 crown - porcelain fused to high noble metal Teeth 4 - 13, 20 - 29 Yes21 and older One per 60 months. Pre-operative radiographs.



Code DescriptionAge


Restorative



Teeth 4 - 13, 20 - 29 Yes21 and older One per 60 months. Pre-operative radiographs.

D2752 crown - porcelain fused to noble metal Teeth 4 - 13, 20 - 29 Yes21 and older One per 60 months. Pre-operative radiographs.

D2790 crown - full cast high noble metal Teeth 1 through 32 Yes21 and older One per 60 months. Pre-operative radiographs.

D2791 crown - full cast predominantly base metal Teeth 1 through 32 Yes21 and older One per 60 months. Pre-operative radiographs.

D2792 crown - full cast noble metal Teeth 1 through 32 Yes21 and older One per 60 months. Pre-operative radiographs.



Code DescriptionAge


Restorative


D2910 recement inlay, onlay, or partial coverage restoration

Teeth 1 through 32 No21 and older

D2915 recement cast or prefabricated post and core


D2920 recement crown Teeth 1 through 32, A through T No21 and older

D2931 prefabricated stainless steel crown - permanent tooth

Teeth 1 through 32 Yes21 and older Authorization required for two (2) or more crowns. Not compensated with construction of permanent crown.


D2932 prefabricated resin crown Teeth 6 - 11, 22 - 27, C - H, M - R Yes21 and older Authorization required for two (2) or more crowns.




Code DescriptionAge


Restorative


D2940 sedative filling Teeth 1 through 32, A through T No21 and older

D2951 pin retention - per tooth, in addidtion to restoration


D2954 prefabricated post and core in addition to crown

Teeth 1 through 32 Yes21 and older Endodontic fill radiograph.



Endodontic services are provided to retain teeth through root canal therapy made necessary due to trauma or carious exposure.

The following guidelines must be followed when providing endodontic services:

The standard of acceptability employed for endodontic procedures requires that the canal(s) be completely filled apically and laterally. In cases where the root canal filling does not meet Doral’s treatment standards, Doral can require the procedure to be redone at no additional cost. Any reimbursement already made for an inadequate service may be recouped after the Doral Consultant reviews the circumstances.

Root canal therapy for permanent teeth includes diagnosis, extirpation of the pulp, shaping and enlarging the canals, temporary fillings, filling and obliteration of root canal(s), and progress radiographs. The fee does not include the final restoration.

Root canals and pulpotomies may not be covered in the following situations:

* Root resorption has started and exfoliation is imminent* Gross periapical or periodontal pathosis is demonstrated radiographically (caries to the furcation, or subcrestal deeming the tooth non-restorable)* The general oral condition does not justify root canal therapy due to the loss of arch integrity* Tooth does not demonstrate 50% bone support* Tooth demonstrates active untreated periodontal disease

Code DescriptionAge


Endodontics


D3310 root canal - anterior (excluding final restoration)

Teeth 6 - 11, 22 - 27 No21 and older Once per lifetime.



Provisions for removable prosthesis included initial placement when masticatory function is impaired or when existing prosthesis is at least five years old and unserviceable.

Payment for dentures includes any necessary adjustments, repairs or relines necessary during the six - (6) month period following delivery of a new prosthesis. Relines are covered once every 24 months. The reimbursement for an incomplete denture service (non-delivery) will be limited to the out-of-pocket costs as documented by a copy of the lab bill. THE DATE OF PLACEMENT MUST BE USED AS THE DATE OF SERVICE WHEN SUBMITTING FOR PAYMENT OF DENTURES. Extractions and other procedures necessary prior to denture placement must be rendered and paid before dentures will be reimbursed. If immediate dentures, extractions must be rendered and billed with the same date of service as placement of the immediate dentures.

In situations where it is impractical to obtain pre-operative radiographs on a patient in a nursing home or long term care facility, a written narrative by the dentist stating that the patient is in a physical and mental state sufficient to function with full dentures is required for authorization.

Denture benefits for patients with the following medical conditions will not be considered for coverage:

* Patients on feeding tubes* Post CVA patients with decreased facial muscle tone* Patients in a coma* Patients with diminished mental capacities that could not function with dentures* Patients who do not desire dentures* Advanced terminal patients

Code DescriptionAge




D5110 complete denture - maxillary Yes21 and older One per 60 months. (D5110 or D5130). Pre-operative full mouth radiographs. Date of prior placement (if applicable).

D5120 complete denture - mandibular Yes21 and older One per 60 months. (D5120 or D5140). Pre-operative full mouth radiographs. Date of prior placement (if applicable).



Code DescriptionAge




D5130 immediate denture - maxillary Yes21 and older One per 60 months. (D5110 or D5130). Pre-operative full mouth radiographs.

D5140 immediate denture - mandibular Yes21 and older One per 60 months. (D5120 or D5140). Pre-operative full mouth radiographs.

D5510 repair broken complete denture base Upper Arch 01 (UA) or Lower Arch 02 (LA)

No21 and older

D5520 replace missing or broken teeth - complete denture (each tooth)


D5610 repair resin denture base Upper Arch 01 (UA) or Lower Arch 02 (LA)

No21 and older



Code DescriptionAge




D5620 repair cast framework Upper Arch 01 (UA) or Lower Arch 02 (LA)

No21 and older

D5630 repair or replace broken clasp No21 and older

D5640 replace broken teeth - per tooth Teeth 1 through 32 No21 and older

D5650 add tooth to existing partial denture Teeth 1 through 32 No21 and older

D5730 reline complete maxillary denture (chairside)

Yes21 and older One per 24 months. Date of denture placement.



Code DescriptionAge




D5731 reline complete mandibular denture (chairside)


D5740 reline maxillary partial denture (chairside) Yes21 and older One per 24 months. Date of denture placement.

D5741 reline mandibular partial denture (chairside) Yes21 and older One per 24 months. Date of denture placement.

D5750 reline complete maxillary denture (laboratory)


D5751 reline complete mandibular denture (laboratory)




Code DescriptionAge




D5760 reline maxillary partial denture (laboratory) Yes21 and older One per 24 months. Date of denture placement.

D5761 reline mandibular partial denture (laboratory)




Code DescriptionAge




D5911 facial moulage (sectional) Yes21 and older Narrative of medical necessity.

D5912 facial moulage (complete) Yes21 and older Narrative of medical necessity.

D5913 nasal prosthesis Yes21 and older Narrative of medical necessity.

D5914 auricular prosthesis Yes21 and older Narrative of medical necessity.

D5915 orbital prosthesis Yes21 and older Narrative of medical necessity.



Code DescriptionAge




D5916 ocular prosthesis Yes21 and older Narrative of medical necessity.

D5919 facial prosthesis Yes21 and older Narrative of medical necessity.

D5922 nasal septal prosthesis Yes21 and older Narrative of medical necessity.

D5923 ocular prosthesis, interim Yes21 and older Narrative of medical necessity.

D5924 cranial prosthesis Yes21 and older Narrative of medical necessity.



Code DescriptionAge




D5925 facial augmentation implant prosthesis Yes21 and older Narrative of medical necessity.

D5926 nasal prosthesis, replacement Yes21 and older Narrative of medical necessity.

D5927 auricular prosthesis, replacement Yes21 and older Narrative of medical necessity.

D5928 orbital prosthesis, replacement Yes21 and older Narrative of medical necessity.

D5929 facial prosthesis, replacement Yes21 and older Narrative of medical necessity.



Code DescriptionAge




D5931 obturator prosthesis, surgical Yes21 and older Narrative of medical necessity.

D5932 obturator prosthesis, definitive Yes21 and older Narrative of medical necessity.

D5933 obturator prosthesis, modification Yes21 and older Narrative of medical necessity.

D5934 mandibular resection prosthesis with guide flange

Yes21 and older Narrative of medical necessity.

D5935 mandibular resection prosthesis without guide flange




Code DescriptionAge




D5936 obturator prosthesis, interim Yes21 and older Narrative of medical necessity.

D5937 trismus appliance (not for TMD treatment) Yes21 and older Not for TMD Treatment. Narrative of medical necessity.

D5951 feeding aid Yes21 and older Narrative of medical necessity.

D5953 speech aid prosthesis, adult Yes21 and older Narrative of medical necessity.

D5954 palatal augmentation prosthesis Yes21 and older Narrative of medical necessity.



Code DescriptionAge




D5955 palatal lift prosthesis, definitive Yes21 and older Narrative of medical necessity.

D5958 palatal lift prosthesis, interim Yes21 and older Narrative of medical necessity.

D5959 palatal lift prosthesis, modification Yes21 and older Narrative of medical necessity.

D5960 speech aid prosthesis, modification Yes21 and older Narrative of medical necessity.

D5982 surgical stent Yes21 and older Narrative of medical necessity.



Code DescriptionAge




D5983 radiation carrier Yes21 and older Narrative of medical necessity.

D5984 radiation shield Yes21 and older Narrative of medical necessity.

D5985 radiation cone locator Yes21 and older Narrative of medical necessity.

D5986 fluoride gel carrier Yes21 and older Narrative of medical necessity.

D5987 commissure splint Yes21 and older Narrative of medical necessity.



Code DescriptionAge




D5988 surgical splint Yes21 and older Narrative of medical necessity.

D5999 unspecified maxillofacial prosthesis, by report




Code DescriptionAge




D6930 recement fixed partial denture No21 and older



Prophylactic removal of multiple asymptomatic teeth, or teeth free from pathology is not a covered benefit.

Extraction of deciduous teeth that radiographically appear to be near imminent exfoliation is not a covered benefit.

Reimbursement includes local anesthesia and post-operative care.

Claims for all oral surgical procedures except simple, non-surgical extractions or for procedure code D7210 must include a pre-operative radiograph to be considered for reimbursement.

Simple and surgical extractions are covered. Local anesthesia and routine post-operative care are included in the fees and will not be reimbursed separately.

“Erupted surgical extractions” are defined as extractions requiring elevation of a mucoperiosteal flap and removal of bone, and/or section of the tooth and closure.

Tuberosity reductions are not payable in conjunction with extractions or alveolectomy in the same quadrant.

For oral surgery performed as part of emergency care, the requirement for prior authorization is waived. Service will still be subject to retrospective review. Emergency care is defined as treatment of pain, infection, swelling, uncontrolled bleeding, or traumatic injury.

PROVIDERS BILLING ANESTHESIA SERVICES WITH ORAL SURGERY SERVICES MUST HAVE THE APPROPRIATE PERMITS IN ORDER TO BE REIMBURSED FOR SEDATION. SEE ANESTHESIA CODES FOR FURTHER DETAIL (D9220 - D9248).

Code DescriptionAge


Oral Surgery


D7140 extraction, erupted tooth or exposed root (elevation and/or forceps removal)


No21 and older

D7210 surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and/or section of tooth


No21 and older Prophylatic removal of asymptomatic tooth or tooth free from pathology is not a covered benefit.




Code DescriptionAge


Oral Surgery


D7220 removal of impacted tooth - soft tissue Teeth 1 through 32, 51 through 82 (SN)

Yes21 and older Prophylatic removal of asymptomatic tooth or tooth free from pathology is not a covered benefit.


D7230 removal of impacted tooth - partially bone Teeth 1 through 32, 51 through 82 (SN)



D7240 removal of impacted tooth - completely bony

Teeth 1 through 32, 51 through 82 (SN)



D7250 surgical removal of residual roots (cutting procedure)




D7450 removal of benign odontogenic cyst or tumor - lesion diameter up to 1.25 cm

Yes21 and older Copy of pathology report with claim.



Code DescriptionAge


Oral Surgery


D7451 removal of benign odontogenic cyst or tumor - lesion diameter greater than 1.25 cm


D7460 removal of benign nonodontogenic cyst or tumor - lesion diameter up to 1.25 cm


D7461 removal of benign nonodontogenic cyst or tumor - lesion diameter greater than 1.25 cm


D7510 incision and drainage of abscess - intraoral soft tissue

Yes21 and older Either D7510 or D7511 on date of service. Pre-operative radiographs and narrative with claim.

D7511 incision and drainage of abscess - intraoral soft tissue - complicated (includes drainage of multiple fascial spaces)

Yes21 and older Includes drainage of multiple fascial spaces. Either D7510 or D7511 on date of service.

Pre-operative radiographs and narrative with claim.



Code DescriptionAge


Oral Surgery


D7610 maxilla - open reduction (teeth immobilized, if present)

Yes21 and older Pre-operative radiographs and accident narrative details with claim.

D7620 maxilla - closed reduction (teeth immobilized, if present)


D7630 mandible - open reduction (teeth immobilized, if present)


D7640 mandible - closed reduction (teeth immobilized, if present)


D7710 maxilla - open reduction Yes21 and older Pre-operative radiographs and accident narrative details with claim.



Code DescriptionAge


Oral Surgery


D7720 maxilla - closed reduction Yes21 and older Pre-operative radiographs and accident narrative details with claim.

D7730 mandible - open reduction Yes21 and older Pre-operative radiographs and accident narrative details with claim.

D7740 mandible - closed reduction Yes21 and older Pre-operative radiographs and accident narrative details with claim.

D7810 open reduction of dislocation Yes21 and older Narrative of medical necessity with claim.

D7820 closed reduction of dislocation Yes21 and older Narrative of medical necessity with claim.



Adjunctive general services include general anesthesia, intravenous sedation, nitrous oxide analgesia, consultations and various drugs and medicaments, and emergency services provided for relief of dental pain.

Procedure code D9110 – palliative treatment is to be used to bill for minor palliative procedures when the only other procedure code billed for is a diagnostic radiograph. If any other services (filling, endodontics, oral surgery etc.) are billed for on the same day, the palliative treatment code will be denied.

Sedation and general anesthesia will only be a covered service for participating dentists that hold the applicable permits required by the Illinois Dental Practice Act.

Requests for sedation and general anesthesia will be reviewed on a case-by-case basis. A case will be covered for Participants with physical or mental health problems of such severity that treatment can not be reasonably attempted without the use of sedation or general anesthesia. Sedation or general anesthesia may be allowed when a surgical procedure is being rendered. Claims for sedation and general anesthesia must include a narrative of medical necessity. Acceptable conditions include:

* Toxicity to local anesthesia supported by documentation;* Severe mental retardation;* Severe physical disability;* Uncontrolled management problem;* Extensive or complicated surgical procedures;* Failure of local anesthesia;* Documented medical complications; and* Acute infection that would preclude the efficacy of local anesthesia.

For cases requiring sedation or general anesthesia, Providers must document the following in the Participant's chart for appropriate psychosomatic disorders: diagnosis, description of past evidence of situational anxiety or uncontrolledbehaviors, and in the case of referral due to uncontrolled behavior, the name of the referring dentist or provider group. Apprehension alone is not typically considered medically necessary. Doral or HFS may elect to perform chart audits on these services. Services not documented as required may be denied for payment. The procedures will only be reimbursed for once per day regardless of the length of time it takes to complete the procedure.

General anesthesia, intravenous sedation, conscious sedation and nitrous oxide are only covered in conjunction with a covered dental procedure. Payment for any one of these services precludes payment for the remaining procedure codes. Payment for general anesthesia, conscious sedation or intravenous sedation includes any other drugs administered on the same day.

Reimbursement for local anesthesia is included in the fee for the procedures.

Procedure code D9230 – nitrous oxide, is a covered service for Participants who are mentally or physically challenged, or otherwise present with special management needs. Special consideration is granted to individuals under the age of six that require extensive dental treatment and/or exhibit rampant caries where patient management is a concern.

Only claims for nitrous oxide with documented medical necessity will be considered for payment. Medical necessity for the use of nitrous oxide would be broadly defined as some condition specific to the particular treatment situation that would preclude the performance of necessary dental treatment, with the use of a local anesthetic alone.



Some examples of conditions that would establish medical necessity for nitrous oxide are:

* Apprehensive child under the age of six when any treatment is rendered* Apprehensive children between 6 and 10 years of age when restorative or surgery is performed* Apprehensive children between the ages of 10 and 18 years when surgical services are performed

All other situations for nitrous oxide will be reviewed for coverage on a case-by-case basis.

Procedure code D9310 – consultation, will only be reimbursed to a dentist other than the one providing definitive treatment. A consultation includes an examination and evaluation of the patient, and a written report from the consultant to the treating dentist. When billing for a consultation, a copy of the written report must be attached. When the consulting dentist also performs services reimbursement to that dentist will be limited to the actual services performed. There will not be a separate reimbursement for a consultation.

Procedure code D9999 is to be utilized to submit a request for reimbursement for a dental service not otherwise described herein. Request should include a description of the service, medical necessity, a proposed fee and any pertinent radiographs.

IN ACCORDANCE WITH THE ILLINOIS DENTAL PRACTICE ACT AS DEFINED IN THE ILLINOIS ADMINISTRATIVE CODE 1220.500, PROCEDURE CODES D9241 AND D9248 REQUIRE A DENTAL SEDATION PERMIT A OR DENTAL SEDATION PERMIT B IN ORDER TO PERFORM SERVICE.

PROCEDURE CODE D9220 REQUIRES AN DENTAL SEDATION PERMIT B IN ORDER TO PERFORM SERVICE.

Code DescriptionAge


Adjunctive General


D9110 palliative (emergency) treatment of dental pain - minor procedure

No21 and older Not covered wth D0140 on same date of service.

D9220 deep sedation/general anesthesia - first 30 minutes

Yes21 and older Requires a Dental Sedation Permit B to perform the services.

Narrative of medical necessity. All inclusive fee - Not limited to first 30 minutes.



Code DescriptionAge


Adjunctive General


D9230 analgesia, anxiolysis, inhalation of nitrous oxide


D9241 intravenous conscious sedation/analgesia - first 30 minutes

Yes21 and older Requires a Dental Sedation Permit A or B to perform the services.

Narrative of medical necessity. All inclusive fee - Not limited to first 30 minutes.

D9248 non-intravenous conscious sedation/analgesia

Yes21 and older Requires a Dental Sedation Permit A or B to perform the services.

Narrative of medical necessity.

D9310 consultation (diagnostic service provided by dentist or physician other than practitioner providing treatment)

No21 and older Narrative of medical necessity shall be maintained in patient records.

D9610 therapeutic drug injection, by report Yes21 and older Narrative of medical necessity. Name of drug and amount administered.



Code DescriptionAge


Adjunctive General


D9630 other drugs and/or medications, by report Yes21 and older Narrative of medical necessity. Name of drug and amount administered.

D9999 unspecified adjunctive procedure, by report

Yes21 and older Description of service and narrative of medical necessity.


Documents

Doral Dental Services of Illinois...Doral Dental Services of Illinois, LLC 10 4) Doral’s Customer Service Department at 888.281.2076 The eligibility information received from either